Form DHS4496 "American Indian Infant Health Initiative (Aiihi) Quarterly Progress Report" - California

What Is Form DHS4496?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2003;
  • The latest edition provided by the California Department of Health Care Services;
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  • Fill out the form in our online filing application.

Download a fillable version of Form DHS4496 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHS4496 "American Indian Infant Health Initiative (Aiihi) Quarterly Progress Report" - California

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State of California—Health and Human Services Agency
Department of Health Services
AMERICAN INDIAN INFANT HEALTH INITIATIVE (AIIHI)
QUARTERLY PROGRESS REPORT
CHR/FSW complete this form every quarter.
Clinic name
[ Clinic Name ]
Year
Quarter ending
2008
March 31
June 30
September 30
December 31
Client/Mother (MOB) Data
MOB ID number
MOB date of birth (mm/dd/yy)
Assessments
Client/MOB New Risk Factors (Check if any new or additional risk factors have been identified since previous encounter.)
None identified
1. Substance abuse or positive toxicity
with
without treatment (explain): ________________________________
OR
2. Maternal Hx of mental illness or developmental delay (parent)
3. Maternal Hx of child abuse, rape, molestation, or incest (as a victim)
4. Age <18 years or >40 years
5. Single, separated (legal or geographical), divorced
6. Self or partner unemployed or seasonal employment
th
7. Education <12
grade or illiterate (English or other language)
8. Inadequate income (<200% FPL or on Medi-Cal)
9. Unstable housing (homeless, frequent moves, overcrowded, multifamily)
10. No telephone or message only
11. Lack of transportation/public transport or dependent on others
12. First-time mother
13. Late (after third trimester), inadequate/sporadic, or no prenatal care
14. Hx of therapeutic abortion (actual or contemplated) or multiple miscarriages
15. Depression or suicidal ideation (past or present)
16. Child(ren) in foster home placement (past or present) or CPS involvement
17. Hx of domestic/family violence or rape/sexual assault (as a victim)
18. Other (e.g., new pregnancy, no support system/person, unplanned pregnancy, unrealistic expectation of child development)
(explain):
19. No changes this quarter
Child(ren) Developmental Assessments (Complete only if new assessments were made.)
Denver Developmental Test:
Normal
Delayed—(Date (mm/dd/yy):
)
Not done
Ages and Stages Questionnaire (ASQ):
Normal
Delayed—(Date (mm/dd/yy):
)
Not done
AIIHI Workbook Developmental Assessment:
Normal
Delayed—(Date (mm/dd/yy):
)
Visits
Scheduled frequency of visits:
Weekly
Biweekly
Monthly
Quarterly
Other
Actual number of home visits
Number of unsuccessful home visit attempts
Number of phone counseling
If no contact was made, indicate the reason (check all that apply):
Client did not want visit
Could not locate client
FOB/family member objected
Other (explain):_______________________________________________________________________________________________
Page 1 of 3
DHS 4496 (5/03)
State of California—Health and Human Services Agency
Department of Health Services
AMERICAN INDIAN INFANT HEALTH INITIATIVE (AIIHI)
QUARTERLY PROGRESS REPORT
CHR/FSW complete this form every quarter.
Clinic name
[ Clinic Name ]
Year
Quarter ending
2008
March 31
June 30
September 30
December 31
Client/Mother (MOB) Data
MOB ID number
MOB date of birth (mm/dd/yy)
Assessments
Client/MOB New Risk Factors (Check if any new or additional risk factors have been identified since previous encounter.)
None identified
1. Substance abuse or positive toxicity
with
without treatment (explain): ________________________________
OR
2. Maternal Hx of mental illness or developmental delay (parent)
3. Maternal Hx of child abuse, rape, molestation, or incest (as a victim)
4. Age <18 years or >40 years
5. Single, separated (legal or geographical), divorced
6. Self or partner unemployed or seasonal employment
th
7. Education <12
grade or illiterate (English or other language)
8. Inadequate income (<200% FPL or on Medi-Cal)
9. Unstable housing (homeless, frequent moves, overcrowded, multifamily)
10. No telephone or message only
11. Lack of transportation/public transport or dependent on others
12. First-time mother
13. Late (after third trimester), inadequate/sporadic, or no prenatal care
14. Hx of therapeutic abortion (actual or contemplated) or multiple miscarriages
15. Depression or suicidal ideation (past or present)
16. Child(ren) in foster home placement (past or present) or CPS involvement
17. Hx of domestic/family violence or rape/sexual assault (as a victim)
18. Other (e.g., new pregnancy, no support system/person, unplanned pregnancy, unrealistic expectation of child development)
(explain):
19. No changes this quarter
Child(ren) Developmental Assessments (Complete only if new assessments were made.)
Denver Developmental Test:
Normal
Delayed—(Date (mm/dd/yy):
)
Not done
Ages and Stages Questionnaire (ASQ):
Normal
Delayed—(Date (mm/dd/yy):
)
Not done
AIIHI Workbook Developmental Assessment:
Normal
Delayed—(Date (mm/dd/yy):
)
Visits
Scheduled frequency of visits:
Weekly
Biweekly
Monthly
Quarterly
Other
Actual number of home visits
Number of unsuccessful home visit attempts
Number of phone counseling
If no contact was made, indicate the reason (check all that apply):
Client did not want visit
Could not locate client
FOB/family member objected
Other (explain):_______________________________________________________________________________________________
Page 1 of 3
DHS 4496 (5/03)
Visits (continued)
Referrals Made in This Quarter (Check all that apply.) (See Suggested Referrals and Sample Goals List.)
Result
Reason for
Result
Reason for
(Y/N/U)*
Non-Use**
(Y/N/U)*
Non-Use**
Childbirth class
Nutrition counseling
Family planning services
TANF
CHDP/well-child care
Medi-Cal
Parenting class
WIC
Mental health counseling
OB care
Family counseling
CPS
Drug and alcohol counseling
Immunizations
Medical (explain):
Educational (explain):
Dental (explain):
Other (explain):
Cultural (explain):
No referral made this quarter
* Y=Yes, client received the referred service; N=No, client did not receive the referred service; U=Unknown whether client received the referred service.
** Reasons for non-use of referred service—Choose the reason why client did not receive the service from the list below:
1. Forgot appointment
6. Not eligible for service
2. FOB/family members objected
7. Negative experience with previous treatment/appointment
3. Problem with child care
8. Too early to assess result, referral made recently
4. Problem with transportation
9. Other
5. Problem with making appointment
10. Unknown
Family Goals (Goals should relate to client's risk factors. See Suggested Referrals and Sample Goals List.)
Not Met/Ongoing
None established yet.
Met
Progress Made
No Progress Made
[ none specified ]
1.
2.
[ none specified ]
3.
[ none specified ]
4.
[ none specified ]
Pregnancy/Birth Data
A. Client currently pregnant
Yes
No
B. Client gave birth this quarter
Type of birth
Date of birth (mm/dd/yy)
weight child #2
weight child #1
_____lbs._______ oz.
_____lbs._______ oz.
Yes
No
Multiple
Singleton
If yes, complete the following:
Preterm (-37 weeks)
Full term (38–42 weeks
Post term (43+ weeks)
Gestation
Stillbirth
Spontaneous abortion
Therapeutic abortion
Birth Complications (Check all that apply.)
Mother
Child #2
Child #1
None
None
None
Medical (including C-section)
Medical
Medical
Drug/alcohol exposure
Drug/alcohol
Drug/alcohol exposure
use-related
Infections
Developmental
Developmental
Other (explain): __________________
Other (explain) ____________________
Other (explain): __________________
C. Client has children under age 5 in home (NOT including the newborn described above
Yes
No
Father (FOB) Data
Date of birth (mm/dd/yy) Age
American Indian
If DOB is unknown, enter estimated age
Involved with pregnancy/child
0
Yes
No
Yes
No
Unknown
Unknown
Page 2 of 3
DHS 4496 (5/03)
Conditions of Client/Family (Choose the answer that best describes client/family this quarter.)
Client’s attitude toward visits:
Not interested
Undecided
Participating
Unknown/not applicable
FOB’s attitude toward visits:
Not interested
Undecided
Participating
Unknown/not applicable
Other family members’ attitude toward visits:
Not interested
Undecided
Participating
Unknown/not applicable
Client’s condition in general:
Unstable*
Unstable* at times
Stable
Unknown/not applicable
Child(ren)’s condition in general:
Unstable**
Unstable** at times
Stable
Unknown/not applicable
Client’s parenting skills:
Unskilled
Some skills
Skilled
Unknown/not applicable
Client’s interactions with child(ren):
No/little interaction
Some interactions
Good interactions
Unknown/not applicable
Client’s relationship with FOB/partner:
Always unstable*
Unstable* at times
Stable
Unknown/not applicable
Client status as of end of this quarter:
Same as start of AIIHI or less stable
Some improvements
Valuable improvements attained
* Client needs additional support to cope with daily stressors.
** The home environment lacks nurturing and support for the child(ren).
Notes:
Family Education (Select the section discussed this quarter)
Guide or Workbook Section(s):
Pregnancy
4–7 months
1–2 years
3–5 years
0–3 months
8 months to 1 year
2–3 years
Parents’ health
Case Disposition
Currently in AIIHI
Active
Inactive (but remains in AIIHI)
Dropped from AIIHI
Date (mm/dd/yy): _______________________
Reason (check all that apply):
Client does not want visit
Cannot locate client
FOB/family member objects
Client stable or independent
Child(ren) over 5 years old
Entered Head Start
Client moved out of area
Other (explain):____________________
Completed by:
Date last updated
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DHS 4496 (5/03)
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