Guidebook to the
Responsible Fatherhood Project
Participant Management Information System

Instructions for Completing
Participant Data Forms

The RFMIS has been developed with five basic forms:

Form 1, Intake Form;
Form 2, Assessment Form;
Form 3, Participant Service Needs Form;
Form 4, Monthly Tracking Form; and
Form 5, Change in Service Needs, Change of Address, and Case Closing Form.

The sections that follow describe the basic procedures to be used by project staff in completing each form. See Section 2 for examples of completed participant forms [in PDF format]. Blank forms may be printed.

INSTRUCTIONS FOR COMPLETING FORM 1, INTAKE FORM

The Intake Form should be completed by site intake staff or case managers at the time of the initial intake interview with a prospective participant. Prospective participants do not need to subsequently enroll in the program for the Intake Form to be completed. This form may be completed either prior to the completion of Form 2 (Assessment Form) or at the same time. Specific instructions for completing this form follow.

QUESTION ON FORM 1 INSTRUCTIONS FOR COMPLETING THE QUESTION

A1. Name Enter participant’s (i.e., client/customer/individual) last name, first name, and middle initial (e.g., Smith, John H.)

A2. Address, City, State, Zip Enter participant’s street address (e.g., 123 Main Street, Apt. #5); city (e.g., Cleveland); appropriate 2-letter abbreviation for the state (e.g., OH); and 5-digit zip code (e.g., 44107). If participant is living with a relative/friend, in a transitional housing facility, or in an emergency shelter at the time of intake, use the address of the relative/friend or facility. If the individual is living on the street, out of his/her car, or otherwise has no fixed addressed, write in "no fixed address."

A3. Home Phone Enter participant’s home telephone number [e.g., (216) 987-6543]. Write in "None" if the individual has no home phone.

A4. Work Phone Enter participant’s work telephone number [e.g., (216) 987-1234]. Write in "None" if the individual has no work phone.

A5. Pager Number Enter participant’s pager/cellular phone number [e.g., (216) 987-5433]. Write in "None" if the individual has no pager/cellular phone.

A6. E-Mail Address Enter participant’s Internet E-mail address (e.g., jsmith@mlbcleve.com). Write in "None" if the individual has no E-mail address.

A7. Social Security Number Enter participant’s 9-digit Social Security Number (123-44-5678).

A8. Where did you hear about the program? [Check all that apply.] Check the source or sources by which the participant heard about the program.

A9. Are you required to attend this program? Check "Yes" or "No" to indicate if the participant was require to attend the program (e.g., as a condition for continued receipt of welfare payments, to avoid imprisonment, or to meet parole requirements).

A10. Date of Birth (MM/DD/YY): Enter the numeric month, day, and year the participant was born (e.g., 05/27/67).

A11. Gender: Check the appropriate box indicating participant’s gender (i.e., male or female).

A12. What is your current marital status? Check the category that best describes the participant’s current legal marital status.

A13. Do you consider yourself: Check the category that best describes the participant’s race/ethnicity. If no category sufficiently describes the participant’s race/ethnicity, then check "Other" and write in the other race/ethnicity.

A14. Are you currently enrolled in school? Check "Yes" or "No" to indicate whether the participant is currently enrolled in high school, junior college/community college, college/university, Adult Basic Education (ABE) or General Equivalency Diploma (GED) program.

A15. What is the highest grade in school you have completed? Enter the highest educational level that the participant completed. If for example, the participant entered the ninth grade, but did not finish the school year, then "8" would be the correct response. Use 1 through 12 to indicate the highest grade completed through high school graduation. For participants who advance beyond high school, enter the following:

13 = Completed 1 year of college/university or community college
14 = Completed 2 years of college/university or community college
15 = Completed 3 years of college/university
16 = Completed 4 years of college/university
18 = Completed a Master’s, Doctoral (Ph.D.), or professional degree

A16. What is the highest degree you have earned? Check the appropriate category to indicate the highest educational degree the participant has earned. GED stands for General Equivalency Diploma; Technical/AA degree stands for a technical degree, certification, or 2-year associate degree (for example through a community college).

A17. In addition to you, who do you normally live with? [Check all that apply.] Check all of the types of individuals who normally live with the participant. Someone "normally" living with the participant would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month. If the individual lives in a halfway house or emergency shelter, check response item 10.

A18. Do you have any children under the age of 18 who do not live with you? Check "Yes" or "No" to indicate whether the participant has any children (under the age of 18) who currently live (e.g., eat, sleep, etc.) with the participant at least half of the days of a typical month.

A19. Are you or is your girlfriend/partner pregnant? Check "Yes" or "No" to indicate whether the participant or the participant’s girlfriend/partner is currently pregnant.

A20. Do you think you might want help with any of the following? [Check all that apply.] Check all of the types of services/assistance the participant indicates he/she needs. [Note: Form 3, Service Plan, provides the case manager/counselor with an opportunity to indicate his/her assessment of the participant’s service needs; this data item on Form 1 should indicate the participant’s perception of service needs.]

***FOR OFFICE USE ONLY***
A21. Is this person appropriate for the program?
Project staff/counselor should indicated whether individual is appropriate for enrollment in the responsible fatherhood program. This would include determination of whether the individual is eligible for services (under site rules) and is in need of and would benefit from available program services.

A22. Project Staff: Enter the last name and first initial of the project staff person (Johnson, K.) who completed the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.

A22. Date: Enter the numeric month, day, and year the form was completed (e.g., 06/25/99)

A23. Participant ID Number: This data item should be left blank at the time the form is completed by project staff. The Participant ID Number will be assigned automatically by the automated management information system at the time the form is initially entered into the system. This number should be written onto the form by the data entry staff person when the form has been entered into the RFMIS. This number should be entered onto subsequent forms as they are completed by project staff (i.e., the Assessment Form, the Participant Service Needs Form, and the Monthly Tracking Form).

A24. Case Notes: Enter any case notes or narrative about the participant, which might include information relevant for determining appropriateness for program participation, special family circumstances, information helpful in determining services needed by the individual, additional contact information, etc. If additional room is needed, notes can be continued on the back of the form.

QUESTION ON FORM 1	INSTRUCTIONS FOR COMPLETING THE QUESTION
A1. Name	Enter participant’s (i.e., client/customer/individual) last name, first name, and middle initial (e.g., Smith, John H.)
A2. Address, City, State, Zip	Enter participant’s street address (e.g., 123 Main Street, Apt. #5); city (e.g., Cleveland); appropriate 2-letter abbreviation for the state (e.g., OH); and 5-digit zip code (e.g., 44107). If participant is living with a relative/friend, in a transitional housing facility, or in an emergency shelter at the time of intake, use the address of the relative/friend or facility. If the individual is living on the street, out of his/her car, or otherwise has no fixed addressed, write in "no fixed address."
A3. Home Phone	Enter participant’s home telephone number [e.g., (216) 987-6543]. Write in "None" if the individual has no home phone.
A4. Work Phone	Enter participant’s work telephone number [e.g., (216) 987-1234]. Write in "None" if the individual has no work phone.
A5. Pager Number	Enter participant’s pager/cellular phone number [e.g., (216) 987-5433]. Write in "None" if the individual has no pager/cellular phone.
A6. E-Mail Address	Enter participant’s Internet E-mail address (e.g., jsmith@mlbcleve.com). Write in "None" if the individual has no E-mail address.
A7. Social Security Number	Enter participant’s 9-digit Social Security Number (123-44-5678).
A8. Where did you hear about the program? [Check all that apply.]	Check the source or sources by which the participant heard about the program.
A9. Are you required to attend this program?	Check "Yes" or "No" to indicate if the participant was require to attend the program (e.g., as a condition for continued receipt of welfare payments, to avoid imprisonment, or to meet parole requirements).
A10. Date of Birth (MM/DD/YY):	Enter the numeric month, day, and year the participant was born (e.g., 05/27/67).
A11. Gender:	Check the appropriate box indicating participant’s gender (i.e., male or female).
A12. What is your current marital status?	Check the category that best describes the participant’s current legal marital status.
A13. Do you consider yourself:	Check the category that best describes the participant’s race/ethnicity. If no category sufficiently describes the participant’s race/ethnicity, then check "Other" and write in the other race/ethnicity.
A14. Are you currently enrolled in school?	Check "Yes" or "No" to indicate whether the participant is currently enrolled in high school, junior college/community college, college/university, Adult Basic Education (ABE) or General Equivalency Diploma (GED) program.
A15. What is the highest grade in school you have completed?	Enter the highest educational level that the participant completed. If for example, the participant entered the ninth grade, but did not finish the school year, then "8" would be the correct response. Use 1 through 12 to indicate the highest grade completed through high school graduation. For participants who advance beyond high school, enter the following: 13 = Completed 1 year of college/university or community college 14 = Completed 2 years of college/university or community college 15 = Completed 3 years of college/university 16 = Completed 4 years of college/university 18 = Completed a Master’s, Doctoral (Ph.D.), or professional degree
A16. What is the highest degree you have earned?	Check the appropriate category to indicate the highest educational degree the participant has earned. GED stands for General Equivalency Diploma; Technical/AA degree stands for a technical degree, certification, or 2-year associate degree (for example through a community college).
A17. In addition to you, who do you normally live with? [Check all that apply.]	Check all of the types of individuals who normally live with the participant. Someone "normally" living with the participant would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month. If the individual lives in a halfway house or emergency shelter, check response item 10.
A18. Do you have any children under the age of 18 who do not live with you?	Check "Yes" or "No" to indicate whether the participant has any children (under the age of 18) who currently live (e.g., eat, sleep, etc.) with the participant at least half of the days of a typical month.
A19. Are you or is your girlfriend/partner pregnant?	Check "Yes" or "No" to indicate whether the participant or the participant’s girlfriend/partner is currently pregnant.
A20. Do you think you might want help with any of the following? [Check all that apply.]	Check all of the types of services/assistance the participant indicates he/she needs. [Note: Form 3, Service Plan, provides the case manager/counselor with an opportunity to indicate his/her assessment of the participant’s service needs; this data item on Form 1 should indicate the participant’s perception of service needs.]
*FOR OFFICE USE ONLY* A21. Is this person appropriate for the program?	Project staff/counselor should indicated whether individual is appropriate for enrollment in the responsible fatherhood program. This would include determination of whether the individual is eligible for services (under site rules) and is in need of and would benefit from available program services.
A22. Project Staff:	Enter the last name and first initial of the project staff person (Johnson, K.) who completed the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.
A22. Date:	Enter the numeric month, day, and year the form was completed (e.g., 06/25/99)
A23. Participant ID Number:	This data item should be left blank at the time the form is completed by project staff. The Participant ID Number will be assigned automatically by the automated management information system at the time the form is initially entered into the system. This number should be written onto the form by the data entry staff person when the form has been entered into the RFMIS. This number should be entered onto subsequent forms as they are completed by project staff (i.e., the Assessment Form, the Participant Service Needs Form, and the Monthly Tracking Form).
A24. Case Notes:	Enter any case notes or narrative about the participant, which might include information relevant for determining appropriateness for program participation, special family circumstances, information helpful in determining services needed by the individual, additional contact information, etc. If additional room is needed, notes can be continued on the back of the form.

INSTRUCTIONS FOR COMPLETING FORM 2, ASSESSMENT FORM

Form 2 (Assessment Form) is intended to capture background information about the responsible fatherhood project participant, including contact information, employment history, and potential barriers to employment and effective parenting, as well as data on each of the participant’s children. Form 2 should be completed by a site case manager or counselor. This form can be completed at the same time as Form 1 (the Intake Form) during the intake interview or, more likely, over the span of several interviews during the assessment process with the participant. This form should only be completed on individuals who are enrolled as program participants.

The first two pages of the form collect data on the participant, while the last two pages of the form collect information on each child of the participant. Note that Pages 3 and 4 of the Assessment Form should be completed on each child -- thus, if the participant has three children (under the age of 18), the case manager would complete separate Pages 3 and 4 on each child. Also note on Question D12 that if the particular child is currently living with the participant, the case manager does not complete Questions D13-D26.

Specific instructions for completing this form follow.

QUESTION ON FORM 2 INSTRUCTIONS FOR COMPLETING THE QUESTION

Name Enter participant’s last name, first name, and middle initial (e.g., Smith, John H.).

Participant ID Number Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) when the form is entered into the RFMIS. The number that is generated by the RFMIS should be entered onto the form at the time of data entry by project staff in data item "A23. Participant ID Number" on Form 1.]

A. CONTACTS

A1. Name (of the First Contact) Enter the last name, first name, and middle initial of an individual (not living with the participant) who will know how to contact the participant if the program loses contact with the individual (e.g., Smith, Beverly S.).

A1. Address, City, State, Zip Enter first contact person’s street address (e.g., 1367 Elm St., Apt. #3); city (e.g., Cleveland Hts.); appropriate 2-letter abbreviation for the state (e.g., OH); and 5-digit zip code (e.g., 44109).

A1. Home Phone Enter first contact person’s home telephone number [e.g., (216) 444-3621]. Write in "None" if the individual has no home phone.

A1. Work Phone Enter first contact person’s work telephone number [e.g., (216) 436-4324]. Write in "None" if the individual has no work phone.

A1. Pager Number Enter first contact person’s pager/cellular phone number [e.g., (216) 422-4136]. Write in "None" if the individual has no pager or cellular phone.

A1. Relationship Enter first contact person’s relationship with the participant [e.g., mother, father, sister, brother, friend, relative, etc.].

A2. Name (of the Second Contact) Enter the last name, first name, and middle initial of a second individual (not living with the participant) who will know how to contact the participant if the program loses contact with the individual (Williamson, Ron D.).

A2. Address, City, State, Zip Enter second contact person’s street address (e.g., 4327 W. Euclid St.); city (e.g., Cleveland); appropriate 2-letter abbreviation for the state (e.g., OH); and 5-digit zip code (e.g., 44111).

A2. Home Phone Enter second contact person’s home telephone number [e.g., (216) 432-5825]. Write in "None" if the individual has no home phone.

A2. Work Phone Enter second contact person’s work telephone number [e.g., (216) 232-4875]. Write in "None" if the individual has no work phone.

A2. Pager Number Enter second contact person’s pager/cellular phone number [e.g., (216) 444-2893]. Write in "None" if the individual has no pager/cellular phone.

A2. Relationship Enter second contact person’s relationship with the participant [e.g., mother, father, sister, brother, friend, relative, etc.].

B. EMPLOYMENT HISTORY

B1. During the past 12 months, did you receive: [Check all that apply.] Check any of the different types of program assistance or payments that an individual had received during the previous year.

B2. Have you ever been employed? If the participant has been employed (including self-employment) in a subsidized or unsubsidized job (i.e., worked for pay), check "Yes;" if the participant has never been employed, check "No." If "No," then skip to Question C1.

B3. Have you ever been employed full-time? If the participant has ever been employed full-time (i.e., 30 or more hours per week) in a subsidized or unsubsidized job (i.e., worked for pay), check "Yes;" if the participant has never been employed full-time, check "No."

B4. What is the longest you ever worked for any one employer full-time? Enter the longest number of years and months that the participant worked for pay full-time for any one employer (e.g., 2 years and 3 months). Note that months should not exceed 11 (i.e., convert months in excess of 11 to years).

B5. Which best describes your employment in the past 12 months? Check the appropriate box indicating employment status of participant over the previous 12 months. Full-time employment is defined as working for pay at a subsidized or unsubsidized job for 30 or more hours per week.

B6. During the past 12 months, about how many months did you work full-time? Enter the number of months over the past 12 months that the participant has worked for pay at a subsidized or unsubsidized job full-time (i.e., for 30 or more hours per week). Round to the nearest month. Use "0" if the individual has not worked full-time for an employer during the past 12 month or worked full-time less than ½ month.

B7. Are you currently employed? Check appropriate box indicating participant’s current employment status. If "No," please indicated the month and year that the participant left his/her last job (e.g., 11/97) and skip to Question B11.

B8. Is this employment full-time or part-time? Check "Full-time" if the participant is currently employed 30 or more hours per week; check "Part-time" if the participant is currently employed less than 30 hours per week.

B9. Is the job expected to end within the next 6 months? Check "Yes" or "No" to indicate if the participant’s current job is expected to end within next 6 months.

B10. Do you have more than one job? Check "Yes" or "No" to indicate if the participant has more than one job.

B11. Are you currently looking for another job? Check "Yes" or "No" to indicate if the participant is currently searching for another job (regardless of whether he/she is or is not currently employed). Looking for another job would include activities such as regularly (at least weekly) looking at job openings in newspapers, on the Internet, or at a public/private employment agency; submitting job applications or resumes to employers; or interviewing for job openings.

B12. When did you start working for your current/most recent employer? Enter numeric month and year (e.g., 04/99) when the participant started working for his/her current or most recent employer. If the participant has more than one job, provide information on the primary job (i.e., the job at which the individual spends the most hours per week working).

B13. Are/were you self-employed? Check "Yes" or "No" to indicate if the participant is (or was) self-employed in his/her current or most recent job.

B14. What kind of work do/did you do? Indicate the participant’s occupation in his/her current or most recent job (e.g., machinist, nurse, cook).

B15. How many hours each week do/did you usually work at this job? Indicate the number of hours each week the participant usually works (or worked) in his/her current or most recent job. If there is considerable week-to-week fluctuation, average the number of hours worked over the four preceding weeks.

B16. What is/was your usual wage before taxes/deductions? $________ per: Enter the participant’s usual gross wages (i.e., before taxes) in his/her current or most recent job, then check the period for which the wages apply (e.g,. $8.50 per hour; $320 per two weeks).

B17. How well does/did this salary cover your financial needs? Enter participant’s assessment of how well the salary from the current or most recent job covers his/her financial needs.

B18. Does/did this job provide you with... [Check all that apply.] Check all of the types of fringe benefits provided through the participant’s current or most recent job. Medical coverage is defined as health insurance that is made available to the participant through the employer and paid either in part or full by the employer. If none of the three types of benefits is/was provided, then check "None of the above."

C. EMPLOYMENT/PARENTING ISSUES

C1. Do you have... Check appropriate responses (Yes or No) to indicate whether the participant has: a valid driver’s license; a photo ID; a Social Security Number; a birth certificate; access to reliable transportation; or a permanent place to live. "Access to Reliable Transportation" means that the participant has regular access to a car, bus transportation, or other transportation services (e.g., car pool, agency operated van; transportation tokens through a provider) to get to and from work.

C2. Do the following make it hard to find or keep a job... Check appropriate responses (Yes or No) to indicate whether any of the following problems make it hard for the participant to find or keep a job: health problems or disabilities; problems with alcohol/drugs; trouble reading or writing; problems speaking English; lack of a green card; or lack of child care. A "green card" is only applicable to immigrants to the United States (enabling immigrants to lawfully work). If the participant has another type of barrier to finding or keeping a job check "Yes" on Item 7 ("Other") and write in the "other" factor on the space provided.

C3. Have you ever been... Check appropriate responses (Yes or No) to indicate whether the participant has ever been: convicted of a misdemeanor; convicted of a felony; convicted of a violent crime; convicted of spousal or child abuse; or involved in an alcohol/drug abuse treatment program; or arrested for driving under the influence (DUI) or driving while intoxicated (DWI).

C4. Have you ever been incarcerated in prison or jail for committing a non-child support related offense? Check appropriate response (Yes or No) to indicate whether participant has been incarcerated in prison or jail for a non-child support related offense. If he or she has been in prison or jail, indicated the most recent month, day, and year of release (e.g., 02/20/99).

C5. Are you currently on... Check appropriate response (Yes or No) to indicate whether the participant is currently on probation or parole.

C6. Do you have any current charges pending? Check appropriate response (Yes or No) to indicate whether the participant has any current criminal charges pending. If the individual has criminal charges pending, indicate the type of charges pending (e.g., burglary).

C7. During the past six months, have you at any time been homeless or lived in an emergency shelter? Check appropriate response (Yes or No) to indicate whether the participant has been homeless or lived in an emergency shelter during the six month period prior to intake.

C8. During the past six months, have you at any time lived in a halfway house? Check appropriate response (Yes or No) to indicate whether the participant has lived in a halfway house during the six month period prior to intake..

C9. How many people normally live in your household? Identify the number of people (including the participant) who normally live with the participant. Someone "normally" living in the same household would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month. Enter 1 if the individual lives alone or by themselves in a homeless shelter, halfway house, or other group living arrangement.

C10. How many children under age 18 do you have? Identify the total number of children (under age 18) the participant has at the time of enrollment in the program.

C11. With how many different women/men have you had these children? Identify the total number of women/men with which the participant has had these children.

C12. How many of these children live with you most of the time? Identify the total number of children that live with the participant most of the time. A child living in the same household most of the time would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month.

C13. Do you have an order through the court or the child support agency that says you are supposed to pay child support for some or all of your children? Check the appropriate response (Yes or No). If the participant has an order through the court or the child support agency that says he/she is supposed to pay child support for some or all of his/her children, indicate the number of child support orders covering the children. If the response is "No," skip to Question C17. The most reliable source of data should be used to answer this question (i.e., if possible, child support records or other administrative data). Check the box (below the question) if child support or other administrative data are used to verify data entered onto this form.

C14. How much are you supposed to pay each month in child support? At the time of enrollment in the program, indicate the dollar amount the participant is supposed to pay each month in child support payments (e.g., $350.40). If the participant has more than one child support order, add together amounts across all orders. The first column on the table should be used to record the participant’s understanding of his/her monthly payment amount; the second column should be used to record the monthly payment amount according to Child Support records. If possible, record amounts for both columns.

C15. During the past 6 months, about what percentage of the child support you were supposed to pay, did you actually pay? Indicate an estimate of the percentage of child support paid as a percentage of what the individual was supposed to pay across all child support orders over the past six months (e.g., 40%). The first column on the table should be used to record the participant’s understanding of his/her percentage paid; the second column should be used to record the percentage paid according to Child Support records. If possible, record amounts for both columns.

C16. How much do you owe in back due child support payments? At the time of enrollment in the program, enter the total amount ($6500.42) of child support the participant owes (i.e., his/her child support arrearage). The first column on the table should be used to record the participant’s understanding of his/her back due child support payment amount; the second column should be used to record the back due child support payment amount according to Child Support records. If possible, record amounts for both columns.

C17. During the past 6 months, have you provided any of these types of support for children of yours who do not live with you? [Check all that apply.] Check all of the types of additional types of assistance/support the participant has provided over the previous six months for children not living with the participant. If some other type of assistance was provided not covered on the list, check data item #7 ("Anything Else") and then write in the type of assistance. If no additional types of informal assistance were provided, check Item 8 ("None of the above").

C18. Project Staff: Enter the last name and first initial of the project staff person (Johnson, K.) who completed or assisted the participant with completion of the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.

C18. Date:___/___/___ Enter the numeric month, day, and year that the form was completed (e.g., 09/24/99).

C19. Case Notes Enter any case notes or narrative about the participant, which might include information relevant for determining appropriateness for program participation, special family circumstances, information helpful in determining services needed by the individual, additional contact information, etc. If additional room is needed, notes can be continued on the back of the form.

D. INFORMATION ABOUT EACH CHILD [COMPLETE THIS FORM FOR EACH CHILD -- This form is for Child ___ of ___.] Indicate in space provided which child this form is being completed on of the total number of children (e.g., Child 1 of 3, Child 2 of 3, etc.). **Note: Pages 3 and 4 of the Assessment Form should be completed on each child of the participant.**

D1. Child’s Name Enter child’s last name, first name, and middle initial (e.g., Barnes, Gale M.).

D2. Child’s Social Security Number Enter child’s 9-digit Social Security Number (421-43-8777)

D3. Name of Child’s Mother/Father Enter the last name, first name, and middle initial of the other parent (e.g., Barnes, Jane M.)

D4. Child’s Date of Birth Enter numeric month, day, and year of the child’s birth (e.g., 11/23/89).

D5. Child’s Gender Indicate the child’s gender.

D6. Do you live with this child’s mother/father? Check appropriate category to indicate how often the participant is living this the other parent. Someone should be considered living "most of the time" in the same household if they live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of the month leading up to program enrollment.

D7. Are you, or were you in the past, ever married to this child’s mother/father? Check "Yes" or "No" to indicate if the participant was previous married to the child’s other parent.

D8. Has legal custody for this child ever been decided by the court? [If no, Skip to Question D10] If legal custody for this child was decided by the court, check "Yes." If "Yes," proceed to the next question. Otherwise, check "No" or "Don’t Know," and skip to Question D10.

D9. If yes, what is the custody arrangement: If the answer to Question D8 was "Yes," then indicate the current custody arrangement for the child. (Note: Check only one response.)

D10. Is your name on the birth certificate as the legal parent or has paternity been established for this child? Check "Yes,""No," or "Don’t Know" to indicate whether the participant is either named on the child’s birth certificate or has had paternity established for the child. Check the box (below the question) if child support or other administrative data are used to verify data entered onto this form.

D11. Is this child covered by a child support order? Check "Yes,""No," or "Don’t Know" to indicate whether the child is covered by a child support order.

D12. With whom does the child usually live? Indicate with whom the child usually lives. (Note: Check only one response.) A child "usually" living in the same household would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month.
If the child lives with the participant (i.e., Item 1, With you, is checked), stop completing the form here and move on to complete additional Pages 3 and 4 of Form 2 on the participant’s other children. If the child does not live with the participant, continue on to Question D13.

D13. Do you have a court order saying you can spend time with this child? Check "Yes" or "No" to indicate whether the participant has received a court order that allows him/her to spend time with the child.

D14. Has the court placed any restrictions on your contact with this child? Check "Yes" or "No" to indicate whether the court has placed restrictions on the participant’s contact with the child. If No, skip to Question D16.

D15. If yes, what kind of restrictions? If participant responded "Yes" to the Question D14, check the appropriate response to indicate the type of restriction imposed on the participant’s contact with the child. (Note: Check only one response.)

D16. Do you have a temporary or permanent restraining order against the other parent of this child? Enter appropriate response ("Yes - Temporary or ex-parte order;" "Yes - Permanent or ex-parte order;" or "No") to indicate whether the participant has placed a temporary or permanent restraining order against the other parent of this child.

D17. Does the other parent of this child have a temporary or permanent restraining order against you? Enter appropriate response ("Yes - Temporary or ex-parte order;" "Yes - Permanent or ex-parte order;" or "No") to indicate whether this child’s other parent has placed a temporary or permanent restraining order against the participant.

D18. How many miles do you live from this child? Enter an estimate of the number of miles the participant lives from the child (e.g., 40 miles).

D19. How long has it been since you last saw this child? Enter an estimate of the amount of time (in months, weeks, and/or days) since the participant last visited with the child (e.g., 3 weeks; 2 days). Weeks should be converted to months if in excess of 4 weeks and days converted to weeks if in excess of 6 days.

D20. During the past 12 months, about how often did you see this child? Check the response that best describes the frequency with which the participant visited this child over the past year: not at all; about once a year; several times a year; one to three times a month; about once a week; or several times a week. (Note: Check only one response.)

D21. Overall, how satisfied are you with the amount of time you spend with this child? Indicate the participant’s level of satisfaction with the amount of time spent with this child (i.e., very satisfied; somewhat satisfied; somewhat dissatisfied; or very dissatisfied).

D22. During the past 12 months, how much influence have you had in making major decisions about such things as this child’s education, religion, and health? Indicate the participant’s assessment of his or her influence over major decisions in this child’s life (i.e., a great deal, some, or none).

D23. Overall, how would you describe your relationship with this child’s other parent? Indicate the participant’s assessment of his or her relationship with this child’s other parent.

D24. Do you think the other parent wants you to have a positive and close relationship with this child? Indicate the participant’s assessment of whether he/her thinks the other parent want the participant to have a positive and close relationship with this child.

D25. Over the past 12 months, how much conflict have you and the other parent had on the following: Indicate the participant’s assessment the level of conflict with the other parent on each item listed. Circle one response for each item listed (i.e., circle 1 [Great Deal], 2 [Some] or 3 [None]), according to the participant’s response).

D26. When you and the other parent of this child have a serious disagreement, how often do you: Indicate the participant’s assessment on each item of what happens when serious disagreements arise. Indicated how often (i.e., circle 1 [Often], 2 [Occasionally], or 3 [Never]) each type of behavior occurs, according to the participant’s response.

Note: The form is now complete on this particular child; complete additional Pages 3 and 4 of this form on each additional child.

QUESTION ON FORM 2	INSTRUCTIONS FOR COMPLETING THE QUESTION
Name	Enter participant’s last name, first name, and middle initial (e.g., Smith, John H.).
Participant ID Number	Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) when the form is entered into the RFMIS. The number that is generated by the RFMIS should be entered onto the form at the time of data entry by project staff in data item "A23. Participant ID Number" on Form 1.]
A. CONTACTS
A1. Name (of the First Contact)	Enter the last name, first name, and middle initial of an individual (not living with the participant) who will know how to contact the participant if the program loses contact with the individual (e.g., Smith, Beverly S.).
A1. Address, City, State, Zip	Enter first contact person’s street address (e.g., 1367 Elm St., Apt. #3); city (e.g., Cleveland Hts.); appropriate 2-letter abbreviation for the state (e.g., OH); and 5-digit zip code (e.g., 44109).
A1. Home Phone	Enter first contact person’s home telephone number [e.g., (216) 444-3621]. Write in "None" if the individual has no home phone.
A1. Work Phone	Enter first contact person’s work telephone number [e.g., (216) 436-4324]. Write in "None" if the individual has no work phone.
A1. Pager Number	Enter first contact person’s pager/cellular phone number [e.g., (216) 422-4136]. Write in "None" if the individual has no pager or cellular phone.
A1. Relationship	Enter first contact person’s relationship with the participant [e.g., mother, father, sister, brother, friend, relative, etc.].
A2. Name (of the Second Contact)	Enter the last name, first name, and middle initial of a second individual (not living with the participant) who will know how to contact the participant if the program loses contact with the individual (Williamson, Ron D.).
A2. Address, City, State, Zip	Enter second contact person’s street address (e.g., 4327 W. Euclid St.); city (e.g., Cleveland); appropriate 2-letter abbreviation for the state (e.g., OH); and 5-digit zip code (e.g., 44111).
A2. Home Phone	Enter second contact person’s home telephone number [e.g., (216) 432-5825]. Write in "None" if the individual has no home phone.
A2. Work Phone	Enter second contact person’s work telephone number [e.g., (216) 232-4875]. Write in "None" if the individual has no work phone.
A2. Pager Number	Enter second contact person’s pager/cellular phone number [e.g., (216) 444-2893]. Write in "None" if the individual has no pager/cellular phone.
A2. Relationship	Enter second contact person’s relationship with the participant [e.g., mother, father, sister, brother, friend, relative, etc.].
B. EMPLOYMENT HISTORY
B1. During the past 12 months, did you receive: [Check all that apply.]	Check any of the different types of program assistance or payments that an individual had received during the previous year.
B2. Have you ever been employed?	If the participant has been employed (including self-employment) in a subsidized or unsubsidized job (i.e., worked for pay), check "Yes;" if the participant has never been employed, check "No." If "No," then skip to Question C1.
B3. Have you ever been employed full-time?	If the participant has ever been employed full-time (i.e., 30 or more hours per week) in a subsidized or unsubsidized job (i.e., worked for pay), check "Yes;" if the participant has never been employed full-time, check "No."
B4. What is the longest you ever worked for any one employer full-time?	Enter the longest number of years and months that the participant worked for pay full-time for any one employer (e.g., 2 years and 3 months). Note that months should not exceed 11 (i.e., convert months in excess of 11 to years).
B5. Which best describes your employment in the past 12 months?	Check the appropriate box indicating employment status of participant over the previous 12 months. Full-time employment is defined as working for pay at a subsidized or unsubsidized job for 30 or more hours per week.
B6. During the past 12 months, about how many months did you work full-time?	Enter the number of months over the past 12 months that the participant has worked for pay at a subsidized or unsubsidized job full-time (i.e., for 30 or more hours per week). Round to the nearest month. Use "0" if the individual has not worked full-time for an employer during the past 12 month or worked full-time less than ½ month.
B7. Are you currently employed?	Check appropriate box indicating participant’s current employment status. If "No," please indicated the month and year that the participant left his/her last job (e.g., 11/97) and skip to Question B11.
B8. Is this employment full-time or part-time?	Check "Full-time" if the participant is currently employed 30 or more hours per week; check "Part-time" if the participant is currently employed less than 30 hours per week.
B9. Is the job expected to end within the next 6 months?	Check "Yes" or "No" to indicate if the participant’s current job is expected to end within next 6 months.
B10. Do you have more than one job?	Check "Yes" or "No" to indicate if the participant has more than one job.
B11. Are you currently looking for another job?	Check "Yes" or "No" to indicate if the participant is currently searching for another job (regardless of whether he/she is or is not currently employed). Looking for another job would include activities such as regularly (at least weekly) looking at job openings in newspapers, on the Internet, or at a public/private employment agency; submitting job applications or resumes to employers; or interviewing for job openings.
B12. When did you start working for your current/most recent employer?	Enter numeric month and year (e.g., 04/99) when the participant started working for his/her current or most recent employer. If the participant has more than one job, provide information on the primary job (i.e., the job at which the individual spends the most hours per week working).
B13. Are/were you self-employed?	Check "Yes" or "No" to indicate if the participant is (or was) self-employed in his/her current or most recent job.
B14. What kind of work do/did you do?	Indicate the participant’s occupation in his/her current or most recent job (e.g., machinist, nurse, cook).
B15. How many hours each week do/did you usually work at this job?	Indicate the number of hours each week the participant usually works (or worked) in his/her current or most recent job. If there is considerable week-to-week fluctuation, average the number of hours worked over the four preceding weeks.
B16. What is/was your usual wage before taxes/deductions? $________ per:	Enter the participant’s usual gross wages (i.e., before taxes) in his/her current or most recent job, then check the period for which the wages apply (e.g,. $8.50 per hour; $320 per two weeks).
B17. How well does/did this salary cover your financial needs?	Enter participant’s assessment of how well the salary from the current or most recent job covers his/her financial needs.
B18. Does/did this job provide you with... [Check all that apply.]	Check all of the types of fringe benefits provided through the participant’s current or most recent job. Medical coverage is defined as health insurance that is made available to the participant through the employer and paid either in part or full by the employer. If none of the three types of benefits is/was provided, then check "None of the above."
C. EMPLOYMENT/PARENTING ISSUES
C1. Do you have...	Check appropriate responses (Yes or No) to indicate whether the participant has: a valid driver’s license; a photo ID; a Social Security Number; a birth certificate; access to reliable transportation; or a permanent place to live. "Access to Reliable Transportation" means that the participant has regular access to a car, bus transportation, or other transportation services (e.g., car pool, agency operated van; transportation tokens through a provider) to get to and from work.
C2. Do the following make it hard to find or keep a job...	Check appropriate responses (Yes or No) to indicate whether any of the following problems make it hard for the participant to find or keep a job: health problems or disabilities; problems with alcohol/drugs; trouble reading or writing; problems speaking English; lack of a green card; or lack of child care. A "green card" is only applicable to immigrants to the United States (enabling immigrants to lawfully work). If the participant has another type of barrier to finding or keeping a job check "Yes" on Item 7 ("Other") and write in the "other" factor on the space provided.
C3. Have you ever been...	Check appropriate responses (Yes or No) to indicate whether the participant has ever been: convicted of a misdemeanor; convicted of a felony; convicted of a violent crime; convicted of spousal or child abuse; or involved in an alcohol/drug abuse treatment program; or arrested for driving under the influence (DUI) or driving while intoxicated (DWI).
C4. Have you ever been incarcerated in prison or jail for committing a non-child support related offense?	Check appropriate response (Yes or No) to indicate whether participant has been incarcerated in prison or jail for a non-child support related offense. If he or she has been in prison or jail, indicated the most recent month, day, and year of release (e.g., 02/20/99).
C5. Are you currently on...	Check appropriate response (Yes or No) to indicate whether the participant is currently on probation or parole.
C6. Do you have any current charges pending?	Check appropriate response (Yes or No) to indicate whether the participant has any current criminal charges pending. If the individual has criminal charges pending, indicate the type of charges pending (e.g., burglary).
C7. During the past six months, have you at any time been homeless or lived in an emergency shelter?	Check appropriate response (Yes or No) to indicate whether the participant has been homeless or lived in an emergency shelter during the six month period prior to intake.
C8. During the past six months, have you at any time lived in a halfway house?	Check appropriate response (Yes or No) to indicate whether the participant has lived in a halfway house during the six month period prior to intake..
C9. How many people normally live in your household?	Identify the number of people (including the participant) who normally live with the participant. Someone "normally" living in the same household would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month. Enter 1 if the individual lives alone or by themselves in a homeless shelter, halfway house, or other group living arrangement.
C10. How many children under age 18 do you have?	Identify the total number of children (under age 18) the participant has at the time of enrollment in the program.
C11. With how many different women/men have you had these children?	Identify the total number of women/men with which the participant has had these children.
C12. How many of these children live with you most of the time?	Identify the total number of children that live with the participant most of the time. A child living in the same household most of the time would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month.
C13. Do you have an order through the court or the child support agency that says you are supposed to pay child support for some or all of your children?	Check the appropriate response (Yes or No). If the participant has an order through the court or the child support agency that says he/she is supposed to pay child support for some or all of his/her children, indicate the number of child support orders covering the children. If the response is "No," skip to Question C17. The most reliable source of data should be used to answer this question (i.e., if possible, child support records or other administrative data). Check the box (below the question) if child support or other administrative data are used to verify data entered onto this form.
C14. How much are you supposed to pay each month in child support?	At the time of enrollment in the program, indicate the dollar amount the participant is supposed to pay each month in child support payments (e.g., $350.40). If the participant has more than one child support order, add together amounts across all orders. The first column on the table should be used to record the participant’s understanding of his/her monthly payment amount; the second column should be used to record the monthly payment amount according to Child Support records. If possible, record amounts for both columns.
C15. During the past 6 months, about what percentage of the child support you were supposed to pay, did you actually pay?	Indicate an estimate of the percentage of child support paid as a percentage of what the individual was supposed to pay across all child support orders over the past six months (e.g., 40%). The first column on the table should be used to record the participant’s understanding of his/her percentage paid; the second column should be used to record the percentage paid according to Child Support records. If possible, record amounts for both columns.
C16. How much do you owe in back due child support payments?	At the time of enrollment in the program, enter the total amount ($6500.42) of child support the participant owes (i.e., his/her child support arrearage). The first column on the table should be used to record the participant’s understanding of his/her back due child support payment amount; the second column should be used to record the back due child support payment amount according to Child Support records. If possible, record amounts for both columns.
C17. During the past 6 months, have you provided any of these types of support for children of yours who do not live with you? [Check all that apply.]	Check all of the types of additional types of assistance/support the participant has provided over the previous six months for children not living with the participant. If some other type of assistance was provided not covered on the list, check data item #7 ("Anything Else") and then write in the type of assistance. If no additional types of informal assistance were provided, check Item 8 ("None of the above").
C18. Project Staff:	Enter the last name and first initial of the project staff person (Johnson, K.) who completed or assisted the participant with completion of the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.
C18. Date:___/___/___	Enter the numeric month, day, and year that the form was completed (e.g., 09/24/99).
C19. Case Notes	Enter any case notes or narrative about the participant, which might include information relevant for determining appropriateness for program participation, special family circumstances, information helpful in determining services needed by the individual, additional contact information, etc. If additional room is needed, notes can be continued on the back of the form.
D. INFORMATION ABOUT EACH CHILD [COMPLETE THIS FORM FOR EACH CHILD -- This form is for Child ___ of ___.] Indicate in space provided which child this form is being completed on of the total number of children (e.g., Child 1 of 3, Child 2 of 3, etc.). Note: Pages 3 and 4 of the Assessment Form should be completed on each child of the participant.
D1. Child’s Name	Enter child’s last name, first name, and middle initial (e.g., Barnes, Gale M.).
D2. Child’s Social Security Number	Enter child’s 9-digit Social Security Number (421-43-8777)
D3. Name of Child’s Mother/Father	Enter the last name, first name, and middle initial of the other parent (e.g., Barnes, Jane M.)
D4. Child’s Date of Birth	Enter numeric month, day, and year of the child’s birth (e.g., 11/23/89).
D5. Child’s Gender	Indicate the child’s gender.
D6. Do you live with this child’s mother/father?	Check appropriate category to indicate how often the participant is living this the other parent. Someone should be considered living "most of the time" in the same household if they live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of the month leading up to program enrollment.
D7. Are you, or were you in the past, ever married to this child’s mother/father?	Check "Yes" or "No" to indicate if the participant was previous married to the child’s other parent.
D8. Has legal custody for this child ever been decided by the court? [If no, Skip to Question D10]	If legal custody for this child was decided by the court, check "Yes." If "Yes," proceed to the next question. Otherwise, check "No" or "Don’t Know," and skip to Question D10.
D9. If yes, what is the custody arrangement:	If the answer to Question D8 was "Yes," then indicate the current custody arrangement for the child. (Note: Check only one response.)
D10. Is your name on the birth certificate as the legal parent or has paternity been established for this child?	Check "Yes,""No," or "Don’t Know" to indicate whether the participant is either named on the child’s birth certificate or has had paternity established for the child. Check the box (below the question) if child support or other administrative data are used to verify data entered onto this form.
D11. Is this child covered by a child support order?	Check "Yes,""No," or "Don’t Know" to indicate whether the child is covered by a child support order.
D12. With whom does the child usually live?	Indicate with whom the child usually lives. (Note: Check only one response.) A child "usually" living in the same household would live (e.g., eat, sleep, etc.) in the same living quarters (e.g., house or apartment) at least half of the days of a typical month. If the child lives with the participant (i.e., Item 1, With you, is checked), stop completing the form here and move on to complete additional Pages 3 and 4 of Form 2 on the participant’s other children. If the child does not live with the participant, continue on to Question D13.
D13. Do you have a court order saying you can spend time with this child?	Check "Yes" or "No" to indicate whether the participant has received a court order that allows him/her to spend time with the child.
D14. Has the court placed any restrictions on your contact with this child?	Check "Yes" or "No" to indicate whether the court has placed restrictions on the participant’s contact with the child. If No, skip to Question D16.
D15. If yes, what kind of restrictions?	If participant responded "Yes" to the Question D14, check the appropriate response to indicate the type of restriction imposed on the participant’s contact with the child. (Note: Check only one response.)
D16. Do you have a temporary or permanent restraining order against the other parent of this child?	Enter appropriate response ("Yes - Temporary or ex-parte order;" "Yes - Permanent or ex-parte order;" or "No") to indicate whether the participant has placed a temporary or permanent restraining order against the other parent of this child.
D17. Does the other parent of this child have a temporary or permanent restraining order against you?	Enter appropriate response ("Yes - Temporary or ex-parte order;" "Yes - Permanent or ex-parte order;" or "No") to indicate whether this child’s other parent has placed a temporary or permanent restraining order against the participant.
D18. How many miles do you live from this child?	Enter an estimate of the number of miles the participant lives from the child (e.g., 40 miles).
D19. How long has it been since you last saw this child?	Enter an estimate of the amount of time (in months, weeks, and/or days) since the participant last visited with the child (e.g., 3 weeks; 2 days). Weeks should be converted to months if in excess of 4 weeks and days converted to weeks if in excess of 6 days.
D20. During the past 12 months, about how often did you see this child?	Check the response that best describes the frequency with which the participant visited this child over the past year: not at all; about once a year; several times a year; one to three times a month; about once a week; or several times a week. (Note: Check only one response.)
D21. Overall, how satisfied are you with the amount of time you spend with this child?	Indicate the participant’s level of satisfaction with the amount of time spent with this child (i.e., very satisfied; somewhat satisfied; somewhat dissatisfied; or very dissatisfied).
D22. During the past 12 months, how much influence have you had in making major decisions about such things as this child’s education, religion, and health?	Indicate the participant’s assessment of his or her influence over major decisions in this child’s life (i.e., a great deal, some, or none).
D23. Overall, how would you describe your relationship with this child’s other parent?	Indicate the participant’s assessment of his or her relationship with this child’s other parent.
D24. Do you think the other parent wants you to have a positive and close relationship with this child?	Indicate the participant’s assessment of whether he/her thinks the other parent want the participant to have a positive and close relationship with this child.
D25. Over the past 12 months, how much conflict have you and the other parent had on the following:	Indicate the participant’s assessment the level of conflict with the other parent on each item listed. Circle one response for each item listed (i.e., circle 1 [Great Deal], 2 [Some] or 3 [None]), according to the participant’s response).
D26. When you and the other parent of this child have a serious disagreement, how often do you:	Indicate the participant’s assessment on each item of what happens when serious disagreements arise. Indicated how often (i.e., circle 1 [Often], 2 [Occasionally], or 3 [Never]) each type of behavior occurs, according to the participant’s response.
Note: The form is now complete on this particular child; complete additional Pages 3 and 4 of this form on each additional child.

INSTRUCTIONS FOR COMPLETING FORM 3, PARTCIPANT SERVICE NEEDS

Form 3 (Participant Service Needs) is intended to capture the project staff (or case manager’s) assessment of the types of assistance or services needed by the participant at the time of enrollment into the program. Form 3 should be completed by the case manager at the end of the assessment process and identify the specific services a participant needs. Similar to Forms 1 and 2, this form should be completed on the participant only once -- and in the early stages of program involvement (i.e., at the end of the assessment). It should be completed at the same time as Form 2 or shortly after Form 2 is completed. If a problem such as alcohol or drug use is identified later, the form can be updated to reflect such a service need, though the form should reflect the service needs of the participant at the time of enrollment into the program.

QUESTION ON FORM 3 INSTRUCTIONS FOR COMPLETING THE QUESTION

Participant Name Enter participant’s (i.e., client/customer/individual) last name, first name, and middle initial (e.g., Doe, Jr., John H.).

Participant ID Number Enter the Participant ID Number assigned to the participant. Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) and should have been entered as one of the last data items on Form 1.]

A. Education/Training/Job Placement Needs

A1. Primary Education/Basic Skills/pre-GED Check box if the participant needs primary education, basic skills instruction, or pre-GED preparation. Primary education refers to education in grades 1-8 (i.e., before high school). Pre-GED (General Equivalency Diploma) preparation involves instruction to enhance basic reading or math skills (i.e., basic literacy) so that an individual can begin study for the GED test. Participants in need of primary education or pre-GED would typically have serious basic skills deficits (e.g., poor reading/math skills).

A2. Secondary Education/GED Preparation Check box if the participant is in need of secondary education or GED preparation. Secondary education refers to instruction in grades 9-12 (i.e., before high school graduation). General Equivalency Diploma (GED) preparation involves instruction to enhancing basic reading or math skills so that an individual can pass the GED test. Participants in need of primary or secondary education or a GED would typically have some type of basic skills deficit (e.g., poor reading/math skills) and may lack a high school diploma.

A3. Post-Secondary Education Check box if the participant is in need of some form of post-secondary education. Post-secondary education refers to formal education after high school leading toward a post-secondary degree (e.g., an associate or B.A.) or certification, such as classroom training at a community college, college/university, or proprietary school.

A4. English as a Second Language (ESL) Check box if the participant is in need of English as a Second Language instruction. ESL refers to instruction in the English language for non-English speaking participants.

A5. Job Club/Job Search Check box if the participant is in need of and appropriate for job club or job search assistance to either secure a job or upgrade his/her current job. Job club is a group session in which participants gather regularly (e.g., daily, several times a week, or weekly) to help structure ongoing job search activity. Job search assistance refers to help with job leads or strategies to find a job provided by an agency counselor either on an individual basis or as part of a group workshop.

A6. Job Referrals Check box if the participant is in need of job leads to find a new job or move to a better job.

A7. OJT/Apprenticeship/Subsidized Job Check box if the participant is in need of and appropriate for placement in an on-the-job training (OJT) slot with an employer, an accredited apprenticeship program, or a subsidized job. OJT refers to on-the-job training, which is training provided by an employer as part of the job. Typically, a portion of the wage will be paid by the agency to the employer and the employer will provide the worker with formal or informal training to upgrade skills. A portion of the job training may be provided at the work site, while additional training may or may not be provided in a classroom setting. Apprenticeship is a rigorous training program (e.g., to become an electrician, plumber, welder, or other skilled tradesperson), which is certified by the state or U.S. Department of Labor. Typically, apprenticeship programs last for 2 to 4 years; involve a combination of on-the-job training and classroom instruction; have a formal curriculum; and offer apprenticeship credentialing at the conclusion of training. A subsidized job refers to a job placement in which the employer receives a payment to cover all or part of the wages of the worker (e.g.., ½ of hourly wages, for up to 35 hours per month, for a six-month period). There may or may not be a commitment to hire after the subsidized work is concluded.

A8. Job Skills Training/Vocational Education Check box if the participant is in need of and appropriate for job skills training or vocational education. Job skills training or vocational education may be short or longer-term training provided in a classroom setting (e.g., at a proprietary school, community college, or college/university) or on-the-job. Training is generally aimed at upgrading skills within a specific occupation and is applicable to a specific job. Training may or may not lead to certification or a degree.

A9. Job Readiness/Life Skills/Pre-Employment Check box if the participant is in need of and appropriate for job readiness, life skills, or pre-employment assistance. Job readiness, life skills, and pre-employment services are often provided as part of a group workshop over several days, a week, or longer. Such sessions are designed to prepare participants to conduct effective job searches and for what can be expected once employed. For example, such workshops may provide help with effective job search strategies, completing a resume, how to interview, how to dress, anger management, budgeting, and a range of other instruction oriented to finding and keeping a job.

A10. Job Retention Services Check box if the participant is in need of job retention services. To receive such services a participant must already be employed. Job retention services are intended to help participants keep jobs. Such help might come through individual or group counseling, mentoring, mediation of conflicts with employers or co-workers, or other services aimed at reducing chances that participant will lose his/her job.

A11. Other (specify): Check box and write in any other type of education, training, or job placement service needed by the participant.

B. CHILD SUPPORT/PARENTING/VISITATION NEEDS

B1. Help with Paternity Establishment Check box if the participant is in need of help with establishing paternity for one or more of his/her children.

B2. Help with Establishing a Child Support Order Check box if the participant needs help establishing a child support order for one or more children.

B3. Help with Modifying a Child Support Order Check box if the participant needs help with modifying conditions or amounts to be paid under an existing child support order for one or more children.

B4. Help with Child Support Arrearage Check box if the participant needs help negotiating repayment of child support arrearage (e.g., temporary relief from repayment of past due amounts or a change in terms of regular repayment under a child support order for one or more children).

B5. Help Establishing/Modifying Visitation Order Check box if the participant needs assistance with establishing/modifying a visitation order for one or more children.

B6. Help Establishing/Modifying Custody Order Check box if the participant needs help with establishing/modifying a custody order for one or more children.

B7. Help Dealing with Child Abuse or Neglect Check box if the participant needs help coping with child abuse or neglect either by the participant, the other parent, or another household member.

B8. Help Establishing a Parenting Plan Check box if the participant needs help establishing a parenting plan, which identifies goals and effective strategies for parenting.

B9. Help Getting to Visit Children Check box if the participant needs help getting to visit his/her children, which may include establishing visitation arrangements, mediation, or other related services.

B10. Mediation Check box if the participant needs help with mediation, which involves assistance with negotiating an agreement between the participant and the other parent of one or more children. Such mediation is generally intended to avoid court action.

B11. Parenting Education Check box if parent education is needed by the participant. Parenting education is generally conducted as part of group workshops (though may involve one-on-one counseling) and is designed around a curriculum. Instruction is intended to enhance parenting skills of participants.

B12. Other (specify): Check box and write in any other type of child support, parenting, or visitation service needed by the participant.

C. OTHER SERVICES

C1. Peer Support Check box if peer support is needed by the participant. Peer support involves group sessions or workshops (e.g., rap sessions) in which participants (usually with the help of a facilitator) discuss parenting, employment, and other issues.

C2. Transportation Assistance Check box if transportation assistance is needed by the participant. Transportation assistance may include bus tokens, reimbursement for gas or mileage, reimbursement for car repair, taxi fare, help with purchasing a car, or other types of assistance to help participants overcome transportation problems.

C3. Child Care Assistance Check box if the participant needs help with child care for one or more children. This type of assistance includes help in finding a child care provider, direct provision of child care, and full/partial payment of child care for a child of the participant.

C4. Medical/Dental/Vision Exams and Treatment Check box if the participant needs help with overcoming a medical, dental, or vision problem(s) that is a barrier to employment or becoming a better parent.

C5. Substance Abuse Treatment/ Counseling Check box if the participant is in need of alcohol or substance abuse treatment or counseling.

C6. Mental Health Treatment/Counseling Check box if the participant needs counseling or treatment for a mental health problem that is a barrier to employment or becoming a better parent.

C7. Vocational Rehabilitation Check box if the participant needs vocational rehabilitation services. Such services are typically provided by a state rehabilitation agency or other contracted service provider to help a participant overcome an injury or other health problem in order to be able to work.

C8. Services Related to Anger Management Check box if the participant needs counseling or other types of assistance on how to control anger.

C9. Service Related to Partner Abuse Check box if the participant needs counseling or assistance related to partner abuse.

C10. Housing Placement/Assistance Check box if the participant needs assistance in securing emergency, transitional, or permanent housing or other types of housing assistance (e.g., help with paying a security deposit, help avoiding eviction, help with housing repairs, help applying for public housing units or other types of subsidized housing, etc.).

C11. Money Management/Budgeting Check box if the participant is in need of help with money management or budgeting. Such services may be provided as part of a workshop (e.g., parenting or job readiness workshop) or by individual counseling.

C12. Other Legal Assistance Check box if the participant is in need of legal assistance, other than related to child support, visitation, or custody.

C13. Clothing/Work Equipment Check box if the participant is in need of work clothing, tools, or other equipment.

C14. Help Obtaining an ID Card Check box if participant needs help with obtaining an ID card (e.g., Social Security Card, driver’s license, or other form of valid identification).

C15. Case Management Check box if the participant needs ongoing case management. This would include ongoing counseling, help with planning/arranging services, and monitoring of participant progress.

C16. Other Advocacy/Referral Service Check box if participant needs other types of advocacy (besides legal services) or referral to other types of services not listed.

C17. Other (specify): Check box and write in any other type of support services needed by the participant.

D. POST-ASSESSMENT CASE STATUS

D1. Were any of the services court-ordered, required as part of a child neglect or abuse case, or required as a condition of parole or probation? Check "Yes,""No," or "Don’t Know" any of the services to be provided are court-ordered, required as part of a child neglect or abuse case, or required as a condition of parole or probation.

D2. Enrollment Status: Check appropriate box to indicated if the individual is enrolled as a participant in the responsible fatherhood program. If enrolled in the responsible fatherhood program, indicate the month, day, and year of enrollment (e.g., 09/23/99).

D3. Project Staff: Enter the last name and first initial of the project staff person (Johnson, K.) who completed or assisted the participant with completion of the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.

D3. Date: Enter the numeric month, day, and year that the form was completed (09/24/99).

D4. Case Notes: Enter any case notes or narrative about the participant, particularly relating to obstacles to employment or parenting, and planned service strategies.

QUESTION ON FORM 3	INSTRUCTIONS FOR COMPLETING THE QUESTION
Participant Name	Enter participant’s (i.e., client/customer/individual) last name, first name, and middle initial (e.g., Doe, Jr., John H.).
Participant ID Number	Enter the Participant ID Number assigned to the participant. Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) and should have been entered as one of the last data items on Form 1.]
A. Education/Training/Job Placement Needs
A1. Primary Education/Basic Skills/pre-GED	Check box if the participant needs primary education, basic skills instruction, or pre-GED preparation. Primary education refers to education in grades 1-8 (i.e., before high school). Pre-GED (General Equivalency Diploma) preparation involves instruction to enhance basic reading or math skills (i.e., basic literacy) so that an individual can begin study for the GED test. Participants in need of primary education or pre-GED would typically have serious basic skills deficits (e.g., poor reading/math skills).
A2. Secondary Education/GED Preparation	Check box if the participant is in need of secondary education or GED preparation. Secondary education refers to instruction in grades 9-12 (i.e., before high school graduation). General Equivalency Diploma (GED) preparation involves instruction to enhancing basic reading or math skills so that an individual can pass the GED test. Participants in need of primary or secondary education or a GED would typically have some type of basic skills deficit (e.g., poor reading/math skills) and may lack a high school diploma.
A3. Post-Secondary Education	Check box if the participant is in need of some form of post-secondary education. Post-secondary education refers to formal education after high school leading toward a post-secondary degree (e.g., an associate or B.A.) or certification, such as classroom training at a community college, college/university, or proprietary school.
A4. English as a Second Language (ESL)	Check box if the participant is in need of English as a Second Language instruction. ESL refers to instruction in the English language for non-English speaking participants.
A5. Job Club/Job Search	Check box if the participant is in need of and appropriate for job club or job search assistance to either secure a job or upgrade his/her current job. Job club is a group session in which participants gather regularly (e.g., daily, several times a week, or weekly) to help structure ongoing job search activity. Job search assistance refers to help with job leads or strategies to find a job provided by an agency counselor either on an individual basis or as part of a group workshop.
A6. Job Referrals	Check box if the participant is in need of job leads to find a new job or move to a better job.
A7. OJT/Apprenticeship/Subsidized Job	Check box if the participant is in need of and appropriate for placement in an on-the-job training (OJT) slot with an employer, an accredited apprenticeship program, or a subsidized job. OJT refers to on-the-job training, which is training provided by an employer as part of the job. Typically, a portion of the wage will be paid by the agency to the employer and the employer will provide the worker with formal or informal training to upgrade skills. A portion of the job training may be provided at the work site, while additional training may or may not be provided in a classroom setting. Apprenticeship is a rigorous training program (e.g., to become an electrician, plumber, welder, or other skilled tradesperson), which is certified by the state or U.S. Department of Labor. Typically, apprenticeship programs last for 2 to 4 years; involve a combination of on-the-job training and classroom instruction; have a formal curriculum; and offer apprenticeship credentialing at the conclusion of training. A subsidized job refers to a job placement in which the employer receives a payment to cover all or part of the wages of the worker (e.g.., ½ of hourly wages, for up to 35 hours per month, for a six-month period). There may or may not be a commitment to hire after the subsidized work is concluded.
A8. Job Skills Training/Vocational Education	Check box if the participant is in need of and appropriate for job skills training or vocational education. Job skills training or vocational education may be short or longer-term training provided in a classroom setting (e.g., at a proprietary school, community college, or college/university) or on-the-job. Training is generally aimed at upgrading skills within a specific occupation and is applicable to a specific job. Training may or may not lead to certification or a degree.
A9. Job Readiness/Life Skills/Pre-Employment	Check box if the participant is in need of and appropriate for job readiness, life skills, or pre-employment assistance. Job readiness, life skills, and pre-employment services are often provided as part of a group workshop over several days, a week, or longer. Such sessions are designed to prepare participants to conduct effective job searches and for what can be expected once employed. For example, such workshops may provide help with effective job search strategies, completing a resume, how to interview, how to dress, anger management, budgeting, and a range of other instruction oriented to finding and keeping a job.
A10. Job Retention Services	Check box if the participant is in need of job retention services. To receive such services a participant must already be employed. Job retention services are intended to help participants keep jobs. Such help might come through individual or group counseling, mentoring, mediation of conflicts with employers or co-workers, or other services aimed at reducing chances that participant will lose his/her job.
A11. Other (specify):	Check box and write in any other type of education, training, or job placement service needed by the participant.
B. CHILD SUPPORT/PARENTING/VISITATION NEEDS
B1. Help with Paternity Establishment	Check box if the participant is in need of help with establishing paternity for one or more of his/her children.
B2. Help with Establishing a Child Support Order	Check box if the participant needs help establishing a child support order for one or more children.
B3. Help with Modifying a Child Support Order	Check box if the participant needs help with modifying conditions or amounts to be paid under an existing child support order for one or more children.
B4. Help with Child Support Arrearage	Check box if the participant needs help negotiating repayment of child support arrearage (e.g., temporary relief from repayment of past due amounts or a change in terms of regular repayment under a child support order for one or more children).
B5. Help Establishing/Modifying Visitation Order	Check box if the participant needs assistance with establishing/modifying a visitation order for one or more children.
B6. Help Establishing/Modifying Custody Order	Check box if the participant needs help with establishing/modifying a custody order for one or more children.
B7. Help Dealing with Child Abuse or Neglect	Check box if the participant needs help coping with child abuse or neglect either by the participant, the other parent, or another household member.
B8. Help Establishing a Parenting Plan	Check box if the participant needs help establishing a parenting plan, which identifies goals and effective strategies for parenting.
B9. Help Getting to Visit Children	Check box if the participant needs help getting to visit his/her children, which may include establishing visitation arrangements, mediation, or other related services.
B10. Mediation	Check box if the participant needs help with mediation, which involves assistance with negotiating an agreement between the participant and the other parent of one or more children. Such mediation is generally intended to avoid court action.
B11. Parenting Education	Check box if parent education is needed by the participant. Parenting education is generally conducted as part of group workshops (though may involve one-on-one counseling) and is designed around a curriculum. Instruction is intended to enhance parenting skills of participants.
B12. Other (specify):	Check box and write in any other type of child support, parenting, or visitation service needed by the participant.
C. OTHER SERVICES
C1. Peer Support	Check box if peer support is needed by the participant. Peer support involves group sessions or workshops (e.g., rap sessions) in which participants (usually with the help of a facilitator) discuss parenting, employment, and other issues.
C2. Transportation Assistance	Check box if transportation assistance is needed by the participant. Transportation assistance may include bus tokens, reimbursement for gas or mileage, reimbursement for car repair, taxi fare, help with purchasing a car, or other types of assistance to help participants overcome transportation problems.
C3. Child Care Assistance	Check box if the participant needs help with child care for one or more children. This type of assistance includes help in finding a child care provider, direct provision of child care, and full/partial payment of child care for a child of the participant.
C4. Medical/Dental/Vision Exams and Treatment	Check box if the participant needs help with overcoming a medical, dental, or vision problem(s) that is a barrier to employment or becoming a better parent.
C5. Substance Abuse Treatment/ Counseling	Check box if the participant is in need of alcohol or substance abuse treatment or counseling.
C6. Mental Health Treatment/Counseling	Check box if the participant needs counseling or treatment for a mental health problem that is a barrier to employment or becoming a better parent.
C7. Vocational Rehabilitation	Check box if the participant needs vocational rehabilitation services. Such services are typically provided by a state rehabilitation agency or other contracted service provider to help a participant overcome an injury or other health problem in order to be able to work.
C8. Services Related to Anger Management	Check box if the participant needs counseling or other types of assistance on how to control anger.
C9. Service Related to Partner Abuse	Check box if the participant needs counseling or assistance related to partner abuse.
C10. Housing Placement/Assistance	Check box if the participant needs assistance in securing emergency, transitional, or permanent housing or other types of housing assistance (e.g., help with paying a security deposit, help avoiding eviction, help with housing repairs, help applying for public housing units or other types of subsidized housing, etc.).
C11. Money Management/Budgeting	Check box if the participant is in need of help with money management or budgeting. Such services may be provided as part of a workshop (e.g., parenting or job readiness workshop) or by individual counseling.
C12. Other Legal Assistance	Check box if the participant is in need of legal assistance, other than related to child support, visitation, or custody.
C13. Clothing/Work Equipment	Check box if the participant is in need of work clothing, tools, or other equipment.
C14. Help Obtaining an ID Card	Check box if participant needs help with obtaining an ID card (e.g., Social Security Card, driver’s license, or other form of valid identification).
C15. Case Management	Check box if the participant needs ongoing case management. This would include ongoing counseling, help with planning/arranging services, and monitoring of participant progress.
C16. Other Advocacy/Referral Service	Check box if participant needs other types of advocacy (besides legal services) or referral to other types of services not listed.
C17. Other (specify):	Check box and write in any other type of support services needed by the participant.
D. POST-ASSESSMENT CASE STATUS
D1. Were any of the services court-ordered, required as part of a child neglect or abuse case, or required as a condition of parole or probation?	Check "Yes,""No," or "Don’t Know" any of the services to be provided are court-ordered, required as part of a child neglect or abuse case, or required as a condition of parole or probation.
D2. Enrollment Status:	Check appropriate box to indicated if the individual is enrolled as a participant in the responsible fatherhood program. If enrolled in the responsible fatherhood program, indicate the month, day, and year of enrollment (e.g., 09/23/99).
D3. Project Staff:	Enter the last name and first initial of the project staff person (Johnson, K.) who completed or assisted the participant with completion of the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.
D3. Date:	Enter the numeric month, day, and year that the form was completed (09/24/99).
D4. Case Notes:	Enter any case notes or narrative about the participant, particularly relating to obstacles to employment or parenting, and planned service strategies.

INSTRUCTIONS FOR COMPLETING FORM 4, MONTHLY TRACKING FORM

Form 4 (Monthly Tracking Form) is intended to capture the services that each participant receives on a monthly basis from the time of enrollment in the responsible fatherhood project through termination from the program. This form should be completed by the case manager at the end of each month on each program participant (up until and including the month of termination from the program) to identify the types of services actually received during the reporting month, employment status during the month, outcomes/milestones achieved, and, if terminated during the reporting month, case closing information. A Form 4 should be completed on each participant for each month the individual is enrolled in the program (e.g., if an individual was enrolled in the program 15 months, there should be a total of 15 Form 4s on the individual).

Specific instructions for completing this form follow.

QUESTION ON FORM 4 INSTRUCTIONS FOR COMPLETING THE QUESTION

Participant Name: Enter participant’s last name, first name, and middle initial (e.g., Doe, Jr., John H.).

Participant ID Number: Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) and should have been entered at the bottom of Form 1.]

A1. Reporting Period (Month/Year): Indicate the numeric month and year of the reporting period (e.g., 11/99).

A2. Check here if program did not have contact with participant during the month: Check the box if the program had no contact (e.g., in-person, by telephone) during the reporting period with the participant. If this box is checked it is still possible that a participant may have received services, attained one or more outcomes/milestones, experienced a change of address, etc.

A3. Check here if individual did not participate in any activity during the month: Check the box if the participant did not participate in any services/activity during the month. If this box is checked, no services should be checked in Sections B-D. It is possible, however, that other parts of the form could be completed, including information about employment status, outcomes/ milestones, address change, or case closing.

B. EDUCATION/TRAINING/JOB PLACEMENT

**Check All Services Received During Month** Place a check mark in the box next to each of the activities listed that the participant attended or received during the reporting month. The assistance/services could be provided by the grantee (using grant funds), provided under subcontract (using grant funds) by another agency, or provided under referral by another agency (using or not using grant funds).

B1. Primary Education, Basic Skills, Pre-GED Primary education refers to education in grades 1-8 (i.e., before high school); basic skills instruction and pre-GED involves instruction to enhance basic reading and math skills generally in anticipation of receiving other types of instruction or to enter GED preparation.

B2. Secondary Education/GED Preparation Secondary education refers to education in grades 9-12 (i.e., before high school graduation). General Equivalency Diploma (GED) preparation involves instruction to enhance basic reading and math skills so that an individual can pass the GED test.

B3. Post-Secondary Education Post-secondary education refers to formal education after high school leading toward a post-secondary degree (e.g., an associate or B.A.) or certification, such as classroom training at a community college, college/university, or proprietary school.

B4. English as a Second Language (ESL) ESL refers to instruction in the English language for non-English speaking participants.

B5. Job Club/Job Search Job club is a group session in which participants gather regularly (i.e., daily, several times a week, or weekly) to help structure ongoing job search activity. Job search assistance refers to help with job leads or strategies to find a job provided by an agency counselor either on an individual basis or as part of a group workshop.

B6. Job Referrals Job referrals typically involve counselor or case manager referrals to job openings.

B7. OJT/Apprenticeship/Subsidized Work OJT refers to on-the-job training, which is training provided by an employer as part of the job. Typically, a portion of the wage will be paid by the agency to the employer and the employer will provide the worker with formal or informal training to upgrade skills. A portion of the job training may be provided at the work site, while additional training may or may not be provided in a classroom setting. Apprenticeship is a rigorous training program (e.g., to become an electrician, plumber, welder, or other skilled tradesperson), which is certified by the state or U.S. Department of Labor. Typically, apprenticeship programs last for 2 to 4 years; involve a combination of on-the-job training and classroom instruction; have a formal curriculum; and offer apprenticeship credentialing at the conclusion of training. A subsidized job refers to a job placement in which the employer receives a payment to cover all or part of the wages of the worker (e.g.., ½ of hourly wages, for up to 35 hours per month, for a six-month period). There may or may not be a commitment to hire after the subsidized work is concluded.

B8. Job Skills Training/Vocational Education Job skills training or vocational education may be short or longer-term training provided in a classroom setting (e.g., at a proprietary school, community college, or college/university) or on-the-job. Training is generally aimed at upgrading skills within a specific occupation and is applicable to a specific job. Training may lead to certification or a degree.

B9. Job Readiness/Life Skills Training/ Pre-Employment Job readiness, life skills, and pre-employment services are often provided as part of a group workshop over several days, a week, or longer. Such sessions are designed to prepare participants to conduct effective job searches and for what can be expected once employed. For example, such workshops may provide help with how to search for a job, how to complete a resume, how to interview, how to dress, anger management, budgeting, and a range of other instruction oriented to finding and keeping a job.

B10. Job Retention Services Job retention services involve a range of services to help keep participants in jobs once they have them, including mentoring on the job, help dealing with conflicts with other workers, and mentoring.

B11. Other: This space is available to write in other types of education, employment, or training services in which the participant was involved during the reporting month (not covered elsewhere on the form).

C. CHILD SUPPORT/PARENTING/VISITATION

**Check All Services Received During Month** Place a check mark in the box next to each of the activities listed that the participant attended or received during the reporting month. The assistance/services could be provided by the grantee (using grant funds), provided under subcontract (using grant funds) by another agency, or provided under referral by another agency (using or not using grant funds).

C1. Help with Paternity Establishment Help with establishing paternity for one or more of the participant’s children.

C2. Help with Establishing a Child Support Order Help establishing a child support order for one or more of the participant’s children.

C3. Help with Modifying a Child Support Order Help with modifying conditions or amounts to be paid under an existing child support order for one or more of the participant’s children.

C4. Help with Child Support Arrearage Help negotiating repayment of child support arrearages (i.e., temporary relief from repayment of past due amounts or a change in terms of regular repayment under a child support order for one or more children).

C5. Help Establishing/Modifying Visitation Order Assistance with establishing/modifying a visitation order for one or more of the participant’s children.

C6. Help Establishing/Modifying Custody Order Help with establishing/modifying a custody order for one or more of the participant’s children.

C7. Help Dealing with Child Abuse or Neglect Help with responding to problems of child abuse or neglect for one or more of the participant’s child.

C8. Help Establishing a Parenting Plan Help with identifying goals and effective strategies for parenting and incorporating them into an overall plan for parenting.

C9. Help Getting to Visit Children Help with gaining access to one or more children.

C10. Mediation Assistance with negotiating an agreement between the participant and the other parent of one or more of the participant’s children. Such mediation is generally intended to avoid court action.

C11. Parenting Education Group workshops (though may involve one-on-one counseling) usually designed around a curriculum and providing instruction to enhance parenting skills of participants. If such sessions/workshops have been attended during the month, indicate the number of days the participant attended the workshops during the reporting month.

C12. Other: Write in any other type of child support, parenting, or visitation services received by the participant during the reporting period.

D. OTHER SERVICES

**Check All Services Received During Month** Place a check mark in the box next to each of the activities listed that the participant attended or received during the reporting month. The assistance/services could be provided by the grantee (using grant funds), provided under subcontract (using grant funds) by another agency, or provided under referral by another agency (using or not using grant funds).

D1. Peer Support Sessions or workshops (usually involving other program participants) designed to discuss parenting, relationships, employment, and a range of other personal issues. If such sessions/workshops have been attended during the month, indicate the number of days the participant attended the workshops during the reporting month.

D2. Transportation Assistance Includes bus tokens, reimbursement for gas or mileage, reimbursement for car repair, taxi fare, help with purchasing a car, or other types of assistance to help participants overcome transportation problems.

D3. Child Care Assistance Includes help in finding a child care provider, direct provision of child care, and full/partial payment of child care expenses for a child of the participant.

D4. Medical/Dental/Vision Exams and Treatment Treatment or other assistance provided to help participants with medical, dental, or vision problems.

D5. Substance Abuse Treatment/ Counseling Treatment or counseling to overcome an alcohol or drug abuse problem, including inpatient or outpatient care.

D6. Mental Health Treatment/Counseling Treatment or counseling for a mental health problem that is a barrier to employment or becoming a better parent.

D7. Vocational Rehabilitation Such services are typically provided by a state rehabilitation agency or other contracted service provider to help a participant overcome an injury or other health problem in order to be able to work.

D8. Services Related to Anger Management Counseling or other types of services to help the participant control anger.

D9. Service Related to Partner Abuse Counseling or other assistance related to eliminating partner abuse.

D10. Housing Placement/Assistance Assistance in securing emergency, transitional, or permanent housing and other types of housing assistance (e.g., help with paying a security deposit, help avoiding eviction, help with housing repairs, or help applying for public housing units or other types of subsidized housing).

D11. Money Management/Budgeting Workshop sessions (e.g., parenting or job readiness workshop) or individual counseling to improve the participant’s money management and budgeting skills.

D12. Other Legal Assistance Provision of legal assistance/services, other than related to child support, visitation, or custody.

D13. Clothing/Work Equipment Help with purchasing or provision of clothing, tools, or other equipment for the workplace.

D14. Help Obtaining an ID Card Help with obtaining an ID card (e.g., Social Security Card, driver’s license, or other form of valid identification).

D15. Case Management Counseling and other one-on-one assistance provided by project staff on an ongoing basis to help keep the participant on track, to help troubleshoot emerging problems, and to monitor progress. Typically, a participant would be assigned to a project staff person.

D16. Other Advocacy/Referral Services Help with other types of advocacy (besides legal services) or referral to other types of referral services not listed.

D17. Other: Write in any other type of support services received by the participant during the reporting period (not covered above).

E. EMPLOYMENT STATUS

E1. Was the participant employed at any time during the reporting month? Based on discussion with the participant, employer, or other reliable sources, indicate whether the participant was employed at any time during the reporting month.

E2. What was participant’s employment status at the end of the reporting month (or at last contact)? Based on discussion with the participant, employer, or other reliable sources, indicate the participant’s employment status as of the end of the reporting period or at the time when the participant was last contacted during the month.

E3. On average (during the month), how many hours did the participant work per week? _____ If the participant worked, indicate in the space provided the number of hours (on average) per week he/she worked during the reporting period.

E4. What was the hourly wage before taxes/deductions? $________ per hour Indicate in the space provided the gross hourly rate the participant was paid. If the rate changed during the month, use the last rate the individual was paid during the month. If the hourly rate is not available, it may be necessary to calculate the hourly rate based on annual, monthly, or weekly salary. For example, if the individual is paid an annual salary, find out how many hours the individual works per week and take these hours times 52; then divide the gross annual salary by the estimate of the number of hours worked per year.

E5. What kind of work did participant do? Indicate the participant’s occupation in his/her job (e.g., machinist, nurse, cook).

E6. Did the participant change or lose a job at any time during the reporting period? Indicate if the participant changed or lost a job during the reporting period.

E7. If participant changed or lost a job, why? [Check all that apply.] If the individual did change or lose a job, check the reason(s) for the job change or loss.

F. OUTCOMES/MILESTONES

F1. Did participant complete or meet any of the following outcomes/milestones during month: [Check all that apply.] Based on discussions with the participant, other project staff, project staff at other agencies, and other available records, please check all of the outcomes/milestones achieved by the participant during the reporting month.

F2. Project Staff: Enter the last name and first initial of the project staff person (Johnson, K.) who completed the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.

F2. Date: Enter the numeric month, day, and year that the form was completed (09/24/99).

F3. Case Notes Enter any case notes or narrative about the participant, particularly relating to receipt of services or outcomes/milestones achieved.

QUESTION ON FORM 4	INSTRUCTIONS FOR COMPLETING THE QUESTION
Participant Name:	Enter participant’s last name, first name, and middle initial (e.g., Doe, Jr., John H.).
Participant ID Number:	Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) and should have been entered at the bottom of Form 1.]
A1. Reporting Period (Month/Year):	Indicate the numeric month and year of the reporting period (e.g., 11/99).
A2. Check here if program did not have contact with participant during the month:	Check the box if the program had no contact (e.g., in-person, by telephone) during the reporting period with the participant. If this box is checked it is still possible that a participant may have received services, attained one or more outcomes/milestones, experienced a change of address, etc.
A3. Check here if individual did not participate in any activity during the month:	Check the box if the participant did not participate in any services/activity during the month. If this box is checked, no services should be checked in Sections B-D. It is possible, however, that other parts of the form could be completed, including information about employment status, outcomes/ milestones, address change, or case closing.
B. EDUCATION/TRAINING/JOB PLACEMENT
Check All Services Received During Month	Place a check mark in the box next to each of the activities listed that the participant attended or received during the reporting month. The assistance/services could be provided by the grantee (using grant funds), provided under subcontract (using grant funds) by another agency, or provided under referral by another agency (using or not using grant funds).
B1. Primary Education, Basic Skills, Pre-GED	Primary education refers to education in grades 1-8 (i.e., before high school); basic skills instruction and pre-GED involves instruction to enhance basic reading and math skills generally in anticipation of receiving other types of instruction or to enter GED preparation.
B2. Secondary Education/GED Preparation	Secondary education refers to education in grades 9-12 (i.e., before high school graduation). General Equivalency Diploma (GED) preparation involves instruction to enhance basic reading and math skills so that an individual can pass the GED test.
B3. Post-Secondary Education	Post-secondary education refers to formal education after high school leading toward a post-secondary degree (e.g., an associate or B.A.) or certification, such as classroom training at a community college, college/university, or proprietary school.
B4. English as a Second Language (ESL)	ESL refers to instruction in the English language for non-English speaking participants.
B5. Job Club/Job Search	Job club is a group session in which participants gather regularly (i.e., daily, several times a week, or weekly) to help structure ongoing job search activity. Job search assistance refers to help with job leads or strategies to find a job provided by an agency counselor either on an individual basis or as part of a group workshop.
B6. Job Referrals	Job referrals typically involve counselor or case manager referrals to job openings.
B7. OJT/Apprenticeship/Subsidized Work	OJT refers to on-the-job training, which is training provided by an employer as part of the job. Typically, a portion of the wage will be paid by the agency to the employer and the employer will provide the worker with formal or informal training to upgrade skills. A portion of the job training may be provided at the work site, while additional training may or may not be provided in a classroom setting. Apprenticeship is a rigorous training program (e.g., to become an electrician, plumber, welder, or other skilled tradesperson), which is certified by the state or U.S. Department of Labor. Typically, apprenticeship programs last for 2 to 4 years; involve a combination of on-the-job training and classroom instruction; have a formal curriculum; and offer apprenticeship credentialing at the conclusion of training. A subsidized job refers to a job placement in which the employer receives a payment to cover all or part of the wages of the worker (e.g.., ½ of hourly wages, for up to 35 hours per month, for a six-month period). There may or may not be a commitment to hire after the subsidized work is concluded.
B8. Job Skills Training/Vocational Education	Job skills training or vocational education may be short or longer-term training provided in a classroom setting (e.g., at a proprietary school, community college, or college/university) or on-the-job. Training is generally aimed at upgrading skills within a specific occupation and is applicable to a specific job. Training may lead to certification or a degree.
B9. Job Readiness/Life Skills Training/ Pre-Employment	Job readiness, life skills, and pre-employment services are often provided as part of a group workshop over several days, a week, or longer. Such sessions are designed to prepare participants to conduct effective job searches and for what can be expected once employed. For example, such workshops may provide help with how to search for a job, how to complete a resume, how to interview, how to dress, anger management, budgeting, and a range of other instruction oriented to finding and keeping a job.
B10. Job Retention Services	Job retention services involve a range of services to help keep participants in jobs once they have them, including mentoring on the job, help dealing with conflicts with other workers, and mentoring.
B11. Other:	This space is available to write in other types of education, employment, or training services in which the participant was involved during the reporting month (not covered elsewhere on the form).
C. CHILD SUPPORT/PARENTING/VISITATION
Check All Services Received During Month	Place a check mark in the box next to each of the activities listed that the participant attended or received during the reporting month. The assistance/services could be provided by the grantee (using grant funds), provided under subcontract (using grant funds) by another agency, or provided under referral by another agency (using or not using grant funds).
C1. Help with Paternity Establishment	Help with establishing paternity for one or more of the participant’s children.
C2. Help with Establishing a Child Support Order	Help establishing a child support order for one or more of the participant’s children.
C3. Help with Modifying a Child Support Order	Help with modifying conditions or amounts to be paid under an existing child support order for one or more of the participant’s children.
C4. Help with Child Support Arrearage	Help negotiating repayment of child support arrearages (i.e., temporary relief from repayment of past due amounts or a change in terms of regular repayment under a child support order for one or more children).
C5. Help Establishing/Modifying Visitation Order	Assistance with establishing/modifying a visitation order for one or more of the participant’s children.
C6. Help Establishing/Modifying Custody Order	Help with establishing/modifying a custody order for one or more of the participant’s children.
C7. Help Dealing with Child Abuse or Neglect	Help with responding to problems of child abuse or neglect for one or more of the participant’s child.
C8. Help Establishing a Parenting Plan	Help with identifying goals and effective strategies for parenting and incorporating them into an overall plan for parenting.
C9. Help Getting to Visit Children	Help with gaining access to one or more children.
C10. Mediation	Assistance with negotiating an agreement between the participant and the other parent of one or more of the participant’s children. Such mediation is generally intended to avoid court action.
C11. Parenting Education	Group workshops (though may involve one-on-one counseling) usually designed around a curriculum and providing instruction to enhance parenting skills of participants. If such sessions/workshops have been attended during the month, indicate the number of days the participant attended the workshops during the reporting month.
C12. Other:	Write in any other type of child support, parenting, or visitation services received by the participant during the reporting period.
D. OTHER SERVICES
Check All Services Received During Month	Place a check mark in the box next to each of the activities listed that the participant attended or received during the reporting month. The assistance/services could be provided by the grantee (using grant funds), provided under subcontract (using grant funds) by another agency, or provided under referral by another agency (using or not using grant funds).
D1. Peer Support	Sessions or workshops (usually involving other program participants) designed to discuss parenting, relationships, employment, and a range of other personal issues. If such sessions/workshops have been attended during the month, indicate the number of days the participant attended the workshops during the reporting month.
D2. Transportation Assistance	Includes bus tokens, reimbursement for gas or mileage, reimbursement for car repair, taxi fare, help with purchasing a car, or other types of assistance to help participants overcome transportation problems.
D3. Child Care Assistance	Includes help in finding a child care provider, direct provision of child care, and full/partial payment of child care expenses for a child of the participant.
D4. Medical/Dental/Vision Exams and Treatment	Treatment or other assistance provided to help participants with medical, dental, or vision problems.
D5. Substance Abuse Treatment/ Counseling	Treatment or counseling to overcome an alcohol or drug abuse problem, including inpatient or outpatient care.
D6. Mental Health Treatment/Counseling	Treatment or counseling for a mental health problem that is a barrier to employment or becoming a better parent.
D7. Vocational Rehabilitation	Such services are typically provided by a state rehabilitation agency or other contracted service provider to help a participant overcome an injury or other health problem in order to be able to work.
D8. Services Related to Anger Management	Counseling or other types of services to help the participant control anger.
D9. Service Related to Partner Abuse	Counseling or other assistance related to eliminating partner abuse.
D10. Housing Placement/Assistance	Assistance in securing emergency, transitional, or permanent housing and other types of housing assistance (e.g., help with paying a security deposit, help avoiding eviction, help with housing repairs, or help applying for public housing units or other types of subsidized housing).
D11. Money Management/Budgeting	Workshop sessions (e.g., parenting or job readiness workshop) or individual counseling to improve the participant’s money management and budgeting skills.
D12. Other Legal Assistance	Provision of legal assistance/services, other than related to child support, visitation, or custody.
D13. Clothing/Work Equipment	Help with purchasing or provision of clothing, tools, or other equipment for the workplace.
D14. Help Obtaining an ID Card	Help with obtaining an ID card (e.g., Social Security Card, driver’s license, or other form of valid identification).
D15. Case Management	Counseling and other one-on-one assistance provided by project staff on an ongoing basis to help keep the participant on track, to help troubleshoot emerging problems, and to monitor progress. Typically, a participant would be assigned to a project staff person.
D16. Other Advocacy/Referral Services	Help with other types of advocacy (besides legal services) or referral to other types of referral services not listed.
D17. Other:	Write in any other type of support services received by the participant during the reporting period (not covered above).
E. EMPLOYMENT STATUS
E1. Was the participant employed at any time during the reporting month?	Based on discussion with the participant, employer, or other reliable sources, indicate whether the participant was employed at any time during the reporting month.
E2. What was participant’s employment status at the end of the reporting month (or at last contact)?	Based on discussion with the participant, employer, or other reliable sources, indicate the participant’s employment status as of the end of the reporting period or at the time when the participant was last contacted during the month.
E3. On average (during the month), how many hours did the participant work per week? _____	If the participant worked, indicate in the space provided the number of hours (on average) per week he/she worked during the reporting period.
E4. What was the hourly wage before taxes/deductions? $________ per hour	Indicate in the space provided the gross hourly rate the participant was paid. If the rate changed during the month, use the last rate the individual was paid during the month. If the hourly rate is not available, it may be necessary to calculate the hourly rate based on annual, monthly, or weekly salary. For example, if the individual is paid an annual salary, find out how many hours the individual works per week and take these hours times 52; then divide the gross annual salary by the estimate of the number of hours worked per year.
E5. What kind of work did participant do?	Indicate the participant’s occupation in his/her job (e.g., machinist, nurse, cook).
E6. Did the participant change or lose a job at any time during the reporting period?	Indicate if the participant changed or lost a job during the reporting period.
E7. If participant changed or lost a job, why? [Check all that apply.]	If the individual did change or lose a job, check the reason(s) for the job change or loss.
F. OUTCOMES/MILESTONES
F1. Did participant complete or meet any of the following outcomes/milestones during month: [Check all that apply.]	Based on discussions with the participant, other project staff, project staff at other agencies, and other available records, please check all of the outcomes/milestones achieved by the participant during the reporting month.
F2. Project Staff:	Enter the last name and first initial of the project staff person (Johnson, K.) who completed the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.
F2. Date:	Enter the numeric month, day, and year that the form was completed (09/24/99).
F3. Case Notes	Enter any case notes or narrative about the participant, particularly relating to receipt of services or outcomes/milestones achieved.

INSTRUCTIONS FOR COMPLETING FORM 5, CHANGE IN SERVICE NEEDS, CHANGE OF ADDRESS, AND CASE CLOSING FORM

Form 5 (Change in Service Needs, Change of Address, and Case Closing Form) is intended to capture changes in service needs and address of participants and contact persons, as well as case closing information. This form should be completed by the case manager on an as needed basis to record changes in the participant’s service needs or address; or to close the participant’s case. It is anticipated that each participant will have several change forms completed on them as they proceed through the program. Specific instructions for completing this form follow.

QUESTION ON FORM 5 INSTRUCTIONS FOR COMPLETING THE QUESTION

Participant Name: Enter participant’s last name, first name, and middle initial (e.g., Doe, Jr., John H.).

Participant ID Number: Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) and should have been entered at the bottom of Form 1.]

Type of Action:

Change in Service Needs
Address Changes
Case Closing
Check the appropriate box or boxes to indicate the type of change being recorded on the form.

A. Education/Training/Job Placement Needs:

CHANGE IN SERVICE NEEDS (**Note: Use "N" to Indicate New Service Need and "D" to Indicate Dropped Service Need) Place a "N" (New) as appropriate to indicate a new service need that has emerged for a participant or "D" (Dropped) as appropriate to indicate a service (previously needed by the participant) that is no longer needed by the participant.

A1. Primary Education, Basic Skills, Pre-GED Primary education refers to education in grades 1-8 (i.e., before high school); basic skills instruction and pre-GED involves instruction to enhance basic reading and math skills generally in anticipation of receiving other types of instruction or to enter GED preparation.

A2. Secondary Education/GED Preparation Secondary education refers to education in grades 9-12 (i.e., before high school graduation). General Equivalency Diploma (GED) preparation involves instruction to enhancing basic reading and math skills so that an individual can pass the GED test.

A3. Post-Secondary Education Post-secondary education refers to formal education after high school leading toward a post-secondary degree (e.g., an associate or B.A.) or certification, such as classroom training at a community college, college/university, or proprietary school.

A4. English as a Second Language (ESL) ESL refers to instruction in the English language for non-English speaking participants.

A5. Job Club/Job Search Job club is a group session in which participants gather regularly (i.e., daily, several times a week, or weekly) to help structure ongoing job search activity. Job search assistance refers to help with job leads or strategies to find a job provided by an agency counselor either on an individual basis or as part of a group workshop.

A6. Job Referrals Job referrals typically involve counselor or case manager referrals to job openings.

A7. OJT/Apprenticeship/Subsidized Work OJT refers to on-the-job training, which is training provided by an employer as part of the job. Typically, a portion of the wage will be paid by the agency to the employer and the employer will provide the worker with formal or informal training to upgrade skills. A portion of the job training may be provided at the work site, while additional training may or may not be provided in a classroom setting. Apprenticeship is a rigorous training program (e.g., to become an electrician, plumber, welder, or other skilled tradesperson), which is certified by the state or U.S. Department of Labor. Typically, apprenticeship programs last for 2 to 4 years; involve a combination of on-the-job training and classroom instruction; have a formal curriculum; and offer apprenticeship credentialing at the conclusion of training. A subsidized job refers to a job placement in which the employer receives a payment to cover all or part of the wages of the worker (e.g.., ½ of hourly wages, for up to 35 hours per month, for a six-month period). There may or may not be a commitment to hire after the subsidized work is concluded.

A8. Job Skills Training/Vocational Education Job skills training or vocational education may be short or longer-term training provided in a classroom setting (e.g., at a proprietary school, community college, or college/university) or on-the-job. Training is generally aimed at upgrading skills within a specific occupation and is applicable to a specific job. Training may lead to certification or a degree.

A9. Job Readiness/Life Skills Training/ Pre-Employment Job readiness, life skills, and pre-employment services are often provided as part of a group workshop over several days, a week, or longer. Such sessions are designed to prepare participants to conduct effective job searches and for what can be expected once employed. For example, such workshops may provide help with how to search for a job, how to complete a resume, how to interview, how to dress, anger management, budgeting, and a range of other instruction oriented to finding and keeping a job.

A10. Job Retention Services Job retention services involve a range of services to help keep participants in jobs once they have them, including mentoring on the job, help dealing with conflicts with other workers, and mentoring.

A11. Other: This space is available to write in other types of education, employment, or training services in which the participant was involved during the reporting month (not covered elsewhere on the form).

B. Child Support/Parenting/Visitation Needs:

CHANGE IN SERVICE NEEDS (**Note: Use "N" to Indicate New Service Need and "D" to Indicate Dropped Service Need) Place a "N" (New) as appropriate to indicate a new service need that has emerged for a participant or "D" (Dropped) as appropriate to indicate a service (previously needed by the participant) that is no longer needed by the participant.

B1. Help with Paternity Establishment Help with establishing paternity for one or more of the participant’s children.

B2. Help with Establishing a Child Support Order Help establishing a child support order for one or more of the participant’s children.

B3. Help with Modifying a Child Support Order Help with modifying conditions or amounts to be paid under an existing child support order for one or more of the participant’s children.

B4. Help with Child Support Arrearage Help negotiating repayment of child support arrearages (i.e., temporary relief from repayment of past due amounts or a change in terms of regular repayment under a child support order for one or more children).

B5. Help Establishing/Modifying Visitation Order Assistance with establishing/modifying a visitation order for one or more of the participant’s children.

B6. Help Establishing/Modifying Custody Order Help with establishing/modifying a custody order for one or more of the participant’s children.

B7. Help Dealing with Child Abuse or Neglect Help with responding to problems of child abuse or neglect for one or more of the participant’s child.

B8. Help Establishing a Parenting Plan Help with identifying goals and effective strategies for parenting and incorporating them into an overall plan for parenting.

B9. Help Getting to Visit Children Help with gaining access to one or more children.

B10. Mediation Assistance with negotiating an agreement between the participant and the other parent of one or more of the participant’s children. Such mediation is generally intended to avoid court action.

B11. Parenting Education Group workshops (though may involve one-on-one counseling) usually designed around a curriculum and providing instruction to enhance parenting skills of participants.

B12. Other: Write in any other type of child support, parenting, or visitation services received by the participant during the reporting period.

C. Other Service Needs:

CHANGE IN SERVICE NEEDS (**Note: Use "N" to Indicate New Service Need and "D" to Indicate Dropped Service Need) Place a "N" (New) as appropriate to indicate a new service need that has emerged for a participant or "D" (Dropped) as appropriate to indicate a service (previously needed by the participant) that is no longer needed by the participant.

C1. Peer Support Sessions or workshops (usually involving other program participants) designed to discuss parenting, relationships, employment, and a range of other personal issues.

C2. Transportation Assistance Includes bus tokens, reimbursement for gas or mileage, reimbursement for car repair, taxi fare, help with purchasing a car, or other types of assistance to help participants overcome transportation problems.

C3. Child Care Assistance Includes help in finding a child care provider, direct provision of child care, and full/partial payment of child care expenses for a child of the participant.

C4. Medical/Dental/Vision Exams and Treatment Treatment or other assistance provided to help participants with medical, dental, or vision problems.

C5. Substance Abuse Treatment/ Counseling Treatment or counseling to overcome an alcohol or drug abuse problem, including inpatient or outpatient care.

C6. Mental Health Treatment/Counseling Treatment or counseling for a mental health problem that is a barrier to employment or becoming a better parent.

C7. Vocational Rehabilitation Such services are typically provided by a state rehabilitation agency or other contracted service provider to help a participant overcome an injury or other health problem in order to be able to work.

C8. Services Related to Anger Management Counseling or other types of services to help the participant control anger.

C9. Service Related to Partner Abuse Counseling or other assistance related to eliminating partner abuse.

C10. Housing Placement/Assistance Assistance in securing emergency, transitional, or permanent housing and other types of housing assistance (e.g., help with paying a security deposit, help avoiding eviction, help with housing repairs, or help applying for public housing units or other types of subsidized housing).

C11. Money Management/Budgeting Workshop sessions (e.g., parenting or job readiness workshop) or individual counseling to improve the participant’s money management and budgeting skills.

C12. Other Legal Assistance Provision of legal assistance/services, other than related to child support, visitation, or custody.

C13. Clothing/Work Equipment Help with purchasing or provision of clothing, tools, or other equipment for the workplace.

C14. Help Obtaining an ID Card Help with obtaining an ID card (e.g., Social Security Card, driver’s license, or other form of valid identification).

C15. Case Management Counseling and other one-on-one assistance provided by project staff on an ongoing basis to help keep the participant on track, to help troubleshoot emerging problems, and to monitor progress. Typically, a participant would be assigned to a project staff person.

C16. Other Advocacy/Referral Services Help with other types of advocacy (besides legal services) or referral to other types of referral services not listed.

C17. Other: Write in any other type of support services received by the participant during the reporting period (not covered above).

D. ADDRESS CHANGE

D1. Address Change - Participant

New Address:______________
City:________State:___ Zip:___
Home Phone: (____)_________
Work Phone: (____)_________
Pager Number: (____)________
E-Mail Address:_____________
If the participant changed his/her address or telephone numbers, enter the new address and/or telephone numbers.

D2. Address Change - Contact Person

Name:____________________
Address:__________________
City:______ State:____ Zip:___
Home Phone: (______)______
Work Phone: (______)______
Pager Number: (______)_____
Relationship:_______________
New Contact or Replace Contact: #1 #2
Change in Data on Existing Contact
If the participant’s contact person changed or if the contact person’s address or telephone numbers changed enter changes in the space provided. Indicate whether the change is for one of the two existing contact persons indicated either on an earlier Form 2 or Form 5; or whether this is a new contact person to replace one of the two contact persons indicated on an earlier Form 2 or Form 5.

E. CASE CLOSING

E1. Date Case Closed: ___/___/___ If the participant was terminated from the program during the reporting period, enter the numeric month, day, and year (e.g., 02/24/00).

E2. Reason for Termination: Check the appropriate category (select only one category) to indicate why the participant was terminated from the program. If none of the categories sufficiently describes the reason for termination, check Item 6 ("Other") and write in the termination reason in the space provided.

F. PROJECT STAFF/CASE NOTES

F1. Project Staff: Enter the last name and first initial of the project staff person (Johnson, K.) who completed the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.

F1. Date: Enter the numeric month, day, and year that the form was completed (09/24/99).

F2. Case Notes: Enter any case notes or narrative about the participant, particularly relating to changes in service needs, changes in address, or case closing.

QUESTION ON FORM 5	INSTRUCTIONS FOR COMPLETING THE QUESTION
Participant Name:	Enter participant’s last name, first name, and middle initial (e.g., Doe, Jr., John H.).
Participant ID Number:	Enter the unique Participant ID Number assigned to the participant. [Note: This number will be assigned automatically by the automated management information system (MIS) and should have been entered at the bottom of Form 1.]
Type of Action: Change in Service Needs Address Changes Case Closing	Check the appropriate box or boxes to indicate the type of change being recorded on the form.
A. Education/Training/Job Placement Needs:
CHANGE IN SERVICE NEEDS (Note: Use "N" to Indicate New Service Need and "D" to Indicate Dropped Service Need)**	Place a "N" (New) as appropriate to indicate a new service need that has emerged for a participant or "D" (Dropped) as appropriate to indicate a service (previously needed by the participant) that is no longer needed by the participant.
A1. Primary Education, Basic Skills, Pre-GED	Primary education refers to education in grades 1-8 (i.e., before high school); basic skills instruction and pre-GED involves instruction to enhance basic reading and math skills generally in anticipation of receiving other types of instruction or to enter GED preparation.
A2. Secondary Education/GED Preparation	Secondary education refers to education in grades 9-12 (i.e., before high school graduation). General Equivalency Diploma (GED) preparation involves instruction to enhancing basic reading and math skills so that an individual can pass the GED test.
A3. Post-Secondary Education	Post-secondary education refers to formal education after high school leading toward a post-secondary degree (e.g., an associate or B.A.) or certification, such as classroom training at a community college, college/university, or proprietary school.
A4. English as a Second Language (ESL)	ESL refers to instruction in the English language for non-English speaking participants.
A5. Job Club/Job Search	Job club is a group session in which participants gather regularly (i.e., daily, several times a week, or weekly) to help structure ongoing job search activity. Job search assistance refers to help with job leads or strategies to find a job provided by an agency counselor either on an individual basis or as part of a group workshop.
A6. Job Referrals	Job referrals typically involve counselor or case manager referrals to job openings.
A7. OJT/Apprenticeship/Subsidized Work	OJT refers to on-the-job training, which is training provided by an employer as part of the job. Typically, a portion of the wage will be paid by the agency to the employer and the employer will provide the worker with formal or informal training to upgrade skills. A portion of the job training may be provided at the work site, while additional training may or may not be provided in a classroom setting. Apprenticeship is a rigorous training program (e.g., to become an electrician, plumber, welder, or other skilled tradesperson), which is certified by the state or U.S. Department of Labor. Typically, apprenticeship programs last for 2 to 4 years; involve a combination of on-the-job training and classroom instruction; have a formal curriculum; and offer apprenticeship credentialing at the conclusion of training. A subsidized job refers to a job placement in which the employer receives a payment to cover all or part of the wages of the worker (e.g.., ½ of hourly wages, for up to 35 hours per month, for a six-month period). There may or may not be a commitment to hire after the subsidized work is concluded.
A8. Job Skills Training/Vocational Education	Job skills training or vocational education may be short or longer-term training provided in a classroom setting (e.g., at a proprietary school, community college, or college/university) or on-the-job. Training is generally aimed at upgrading skills within a specific occupation and is applicable to a specific job. Training may lead to certification or a degree.
A9. Job Readiness/Life Skills Training/ Pre-Employment	Job readiness, life skills, and pre-employment services are often provided as part of a group workshop over several days, a week, or longer. Such sessions are designed to prepare participants to conduct effective job searches and for what can be expected once employed. For example, such workshops may provide help with how to search for a job, how to complete a resume, how to interview, how to dress, anger management, budgeting, and a range of other instruction oriented to finding and keeping a job.
A10. Job Retention Services	Job retention services involve a range of services to help keep participants in jobs once they have them, including mentoring on the job, help dealing with conflicts with other workers, and mentoring.
A11. Other:	This space is available to write in other types of education, employment, or training services in which the participant was involved during the reporting month (not covered elsewhere on the form).
B. Child Support/Parenting/Visitation Needs:
CHANGE IN SERVICE NEEDS (Note: Use "N" to Indicate New Service Need and "D" to Indicate Dropped Service Need)**	Place a "N" (New) as appropriate to indicate a new service need that has emerged for a participant or "D" (Dropped) as appropriate to indicate a service (previously needed by the participant) that is no longer needed by the participant.
B1. Help with Paternity Establishment	Help with establishing paternity for one or more of the participant’s children.
B2. Help with Establishing a Child Support Order	Help establishing a child support order for one or more of the participant’s children.
B3. Help with Modifying a Child Support Order	Help with modifying conditions or amounts to be paid under an existing child support order for one or more of the participant’s children.
B4. Help with Child Support Arrearage	Help negotiating repayment of child support arrearages (i.e., temporary relief from repayment of past due amounts or a change in terms of regular repayment under a child support order for one or more children).
B5. Help Establishing/Modifying Visitation Order	Assistance with establishing/modifying a visitation order for one or more of the participant’s children.
B6. Help Establishing/Modifying Custody Order	Help with establishing/modifying a custody order for one or more of the participant’s children.
B7. Help Dealing with Child Abuse or Neglect	Help with responding to problems of child abuse or neglect for one or more of the participant’s child.
B8. Help Establishing a Parenting Plan	Help with identifying goals and effective strategies for parenting and incorporating them into an overall plan for parenting.
B9. Help Getting to Visit Children	Help with gaining access to one or more children.
B10. Mediation	Assistance with negotiating an agreement between the participant and the other parent of one or more of the participant’s children. Such mediation is generally intended to avoid court action.
B11. Parenting Education	Group workshops (though may involve one-on-one counseling) usually designed around a curriculum and providing instruction to enhance parenting skills of participants.
B12. Other:	Write in any other type of child support, parenting, or visitation services received by the participant during the reporting period.
C. Other Service Needs:
CHANGE IN SERVICE NEEDS (Note: Use "N" to Indicate New Service Need and "D" to Indicate Dropped Service Need)**	Place a "N" (New) as appropriate to indicate a new service need that has emerged for a participant or "D" (Dropped) as appropriate to indicate a service (previously needed by the participant) that is no longer needed by the participant.
C1. Peer Support	Sessions or workshops (usually involving other program participants) designed to discuss parenting, relationships, employment, and a range of other personal issues.
C2. Transportation Assistance	Includes bus tokens, reimbursement for gas or mileage, reimbursement for car repair, taxi fare, help with purchasing a car, or other types of assistance to help participants overcome transportation problems.
C3. Child Care Assistance	Includes help in finding a child care provider, direct provision of child care, and full/partial payment of child care expenses for a child of the participant.
C4. Medical/Dental/Vision Exams and Treatment	Treatment or other assistance provided to help participants with medical, dental, or vision problems.
C5. Substance Abuse Treatment/ Counseling	Treatment or counseling to overcome an alcohol or drug abuse problem, including inpatient or outpatient care.
C6. Mental Health Treatment/Counseling	Treatment or counseling for a mental health problem that is a barrier to employment or becoming a better parent.
C7. Vocational Rehabilitation	Such services are typically provided by a state rehabilitation agency or other contracted service provider to help a participant overcome an injury or other health problem in order to be able to work.
C8. Services Related to Anger Management	Counseling or other types of services to help the participant control anger.
C9. Service Related to Partner Abuse	Counseling or other assistance related to eliminating partner abuse.
C10. Housing Placement/Assistance	Assistance in securing emergency, transitional, or permanent housing and other types of housing assistance (e.g., help with paying a security deposit, help avoiding eviction, help with housing repairs, or help applying for public housing units or other types of subsidized housing).
C11. Money Management/Budgeting	Workshop sessions (e.g., parenting or job readiness workshop) or individual counseling to improve the participant’s money management and budgeting skills.
C12. Other Legal Assistance	Provision of legal assistance/services, other than related to child support, visitation, or custody.
C13. Clothing/Work Equipment	Help with purchasing or provision of clothing, tools, or other equipment for the workplace.
C14. Help Obtaining an ID Card	Help with obtaining an ID card (e.g., Social Security Card, driver’s license, or other form of valid identification).
C15. Case Management	Counseling and other one-on-one assistance provided by project staff on an ongoing basis to help keep the participant on track, to help troubleshoot emerging problems, and to monitor progress. Typically, a participant would be assigned to a project staff person.
C16. Other Advocacy/Referral Services	Help with other types of advocacy (besides legal services) or referral to other types of referral services not listed.
C17. Other:	Write in any other type of support services received by the participant during the reporting period (not covered above).
D. ADDRESS CHANGE
D1. Address Change - Participant New Address:______________ City:________State:___ Zip:___ Home Phone: (____)_________ Work Phone: (____)_________ Pager Number: (____)________ E-Mail Address:_____________	If the participant changed his/her address or telephone numbers, enter the new address and/or telephone numbers.
D2. Address Change - Contact Person Name:____________________ Address:__________________ City:______ State:____ Zip:___ Home Phone: (______)______ Work Phone: (______)______ Pager Number: (______)_____ Relationship:_______________ New Contact or Replace Contact: #1 #2 Change in Data on Existing Contact	If the participant’s contact person changed or if the contact person’s address or telephone numbers changed enter changes in the space provided. Indicate whether the change is for one of the two existing contact persons indicated either on an earlier Form 2 or Form 5; or whether this is a new contact person to replace one of the two contact persons indicated on an earlier Form 2 or Form 5.
E. CASE CLOSING
E1. Date Case Closed: ___/___/___	If the participant was terminated from the program during the reporting period, enter the numeric month, day, and year (e.g., 02/24/00).
E2. Reason for Termination:	Check the appropriate category (select only one category) to indicate why the participant was terminated from the program. If none of the categories sufficiently describes the reason for termination, check Item 6 ("Other") and write in the termination reason in the space provided.
F. PROJECT STAFF/CASE NOTES
F1. Project Staff:	Enter the last name and first initial of the project staff person (Johnson, K.) who completed the form. Alternatively, a staff person code number/name may be used by sites in place of the staff person’s name.
F1. Date:	Enter the numeric month, day, and year that the form was completed (09/24/99).
F2. Case Notes:	Enter any case notes or narrative about the participant, particularly relating to changes in service needs, changes in address, or case closing.

Where to?

Main Page and Table of Contents
Introduction
Instructions for Completing Participant Data Forms
Blank Participant Data Forms
Example of a Completed Set of Participant Data Entry Forms
Guide to Using the Responsible Fatherhood Management Information System
Sample Data Entry Screens
RFMIS Data Fields
Guide to Generating Sample Reports and Designing New Reports

Home Pages:
Assistant Secretary for Planning and Evaluation (ASPE)
Child Support Enforcement (OCSE)
U.S. Department of Health and Human Services (HHS)

Revised 5/26/00

Guidebook to the Responsible Fatherhood Project Participant Management Information System

Instructions for Completing Participant Data Forms