M7A

MIECHV Baby’s Age 3 Months

Index Parent

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Parent ID #:

Name of Index Parent:

Date data gathered: / / 20

1.	What are the 2 most recent dates that a validated Parent-Child Interaction Tool (CHEERS Check-In (CCI) Tool for HFA) was done with the Parent and Home Visitor?

(Only enter if client is enrolled in Healthy Families Oregon)

a. Date of PCI: / / 20

b. Date of PCI: / / 20 (if completed)