Wff Confidential Cover Sheet Page 4
ADVERTISEMENT
1
2
3
4
5
6
7WFF HNF Screening Tool
Respondent Study ID# __ __ __ - __ __ __
Y
N
DK
ES
O
SCORING
I
NSTRUCTIONS
1
7. Are there any children under 18 who are or will be living with you?
(I
), Starting with the oldest, please tell me their names and ages, and
F YES
whether they are currently living with you or will be living with you when you
enter housing:
Name
Age
Currently Living
(I
N
) Do you
(I
Y
)
F
O
F
ES
With you?
have a reunification- Reunification Date
date set?
Y
N
Y
N
D
/ M
/
ES
O
ES
O
AY
ONTH
Y
EAR
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
Follow up with
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
WFF for a case
consultation if
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
none of the
children are
currently living
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
in household.
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
___Mos or ___Yrs.
__ __ /__ __ /_ _ _ _
STOP if
“no”for
7 AND 8
Y
N
DK
ES
O
8. Are you or any other adult in your household currently pregnant?
if 8 is yes:
____
9. How many times have you moved in the past 12 months?
____
TIMES
1
S
:
PECIAL SITUATIONS
A child staying elsewhere temporarily (e.g. with a relative, in juvenile detention for a few days, or having a brief
hospitalization) should be considered as currently living with the family.
A child that has been permanently removed from the family should not be considered as currently living with the family.
Page 4 of 7 – Prepared by Westat
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business