Lsp Data Entry Form
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1LSP Data Entry Form
Reset Form
Prior to submittal, LSP Data Entry Forms should be reviewed by supervising staff
One LSP should be done per family. If there is more than one child, only complete the LSP for the youngest child.
Parent Educator:
Agreement #:
If LSP original # different than
Client/Family ID (three numbers-three letters):
client ID specify in pink box
(e.g. LAO-123)
PARENT INFORMATION
Individual #
Parent’s First Name: ______________
1 = Mother
(1)
Parent’s Date of Birth: ____/____/____
2 = Father
(2)
Parent’s Race/Ethnicity:
3 = Guardian (3)
Primary Language Spoken in the Home:
Date family began receiving services: ____/____/______
Parent’s Gender:
Male
Female
Pregnant:
Yes
No
Initial LSP ____/____/_____
Ongoing LSP ____/____/_____
Closing LSP ____/____/____
Date next LSP due: ____/____/______
# Months of service: _____
# Attempted visits:
# Completed visits: ____
Home visitor initials: _____
Contractor Name: _____________________________________
CHILD INFORMATION
Child’s First Name: _____________________
Child’s Date of Birth: ____/____/______
Child’s Race/Ethnicity:
Child’s Gender:
Male
Female
LSP SCORES
All scales are required at intake EXCEPT numbers 36-41 (communication, gross motor, fine motor, problem
solving, personal-social, and social-emotional).
Shaded scales are also required to be scored every six months for follow-up. Non-shaded scales may be scored
every six months as needed.
Scale
Score
Scale
Score
Scale
Score
1. Family/extended family
17. Prenatal care
30. Housing
2. BF, FOB, spouse
18. Parent sick care
31. Food/nutrition
3. Friends/peers
19. Family planning
32. Transportation
4. Attitudes to
20. Child well care
33. Medical/health insurance
pregnancy
5. Nurturing
21. Child sick care
34. Income
6. Discipline
22. Child dental care
35. Child care
7. Support of
23. Child immunizations
Infant/Toddler Development
development
8. Safety
24. Substance use/abuse
36. Communication
9. Relationship w/HV
25. Tobacco use
37. Gross motor
10. Use of information
26. Depression/suicide
38. Fine motor
11. Use of resources
27. Mental illness
39. Problem solving
12. Language
28. Self-esteem
40. Personal-social
13. Educ. <12 yrs
29. Cognitive ability
41. Social-emotional
14. Education
42. Regulation
15. Employment
43. Breast feeding
16. Immigration
PRINT FORM
7/26/11
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