M3

MIECHV ENROLLMENT TOOL

Index Parent

To be completed within 6 months of parent’s enrollment

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

Part A: IPV (Intimate Partner Violence) Screening

IPV refers to physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner. To meet the measure, all clients must be screened for IPV within 6 months of enrollment, regardless of relationship status or if IPV has been previously identified.

1.	Was an approved IPV screening tool (WAST, OAS, HITS, RAT) completed?

Yes, completed → Date tool completed: / / 20 → Go to Question 1a.

1a. If yes, did the client screen for being at risk of IPV?:

Client scored at risk

Client did not score at risk

1b. Which screening tool did you use? WAST OAS HITS RAT

No, not completed → Complete IPV Screening at future visit before the client reaches

6-months post-enrollment, then complete another M3 form and update in THEO.

Part B: IPV Referral

For clients who screen at risk for IPV: Provide IPV referral information at least once preferably before the caregiver has been enrolled for six months.	For clients who do not screen at risk for IPV: Provide IPV referral information at least once preferably before the caregiver has been enrolled for six months. Oregon MIECHV universal referral policy requires that all clients receive information about IPV services. The focus is on provision of information, not whether the client received services, as a client may not be ready or able to access a referral service safely or be able to provide accurate responses to the screening questions.

*Referral information can include:	Domestic violence advocacy program, shelter or hotlines	“Connected Parents, Connected Kids” cards	Housing options or emergency shelter services	Legal advocacy and assistance	Crisis assistance	Support groups	Counseling services to address related needs such as depression or substance use

2. Did you provide referral information?
*See examples in the box

Yes → Date referral information given / / 20

No → Provide referral information at future visit, then complete another M3 form and update in THEO.