UPDATED CMDB Field

Case Management Database Fields
Demographic and Home VisitInformation: To be completedduringfirstmeeting(clientscanbe
assignedcase numbersothat thisinformationdoesnothave tobe enteredmore thanonce).
FOR OFFICE USE ONLY
Variable Name Question(Variable Label) Response options
(numeric,text,check
box needed,etc.)
QuantifiedResponses
P1_Fed_ID Federal ID Numeric
P2_Fed_ID Federal ID Numeric
UGAFam_ID UGA FamilyID
ProjectYear
Cluster
EnrollmentNumber
Program
ParticipantID
Numeric,with
followingcheck
boxes:(#-##-####-
###-#)
Numeric(1,
2, 3, 4, 5)
Numeric(01,
02, 03)
Numeric
Text(ELE or
TWC)
Numeric(1
or 2)
P_ID ParticipantID:UGA FamilyID-1(if
P1) or UGA FamilyID-2 (if P2)
P1_UGASurv_ID UGA Survey(Back-up) ID:Participant
1
Numeric, with
followingcheck
boxes:(#-##-##-
####-###-#####)
Text(Mor F)
Numeric
(mm)
Numeric(dd)
Numeric
(year)
Text
Numeric(zip
code)
P2_UGASurv_ID UGA Survey(Back-up) ID:Participant
2 (if applicable)
Numeric, with
followingcheck
boxes:(#-##-##-
####-###-#####)
Text(Mor F)
Numeric
(mm)
Numeric(dd)
Numeric
(year)

Text
Numeric(zip
code)
DFCS_Reg DFCS Region/Cluster 1- Cluster1
2- Cluster2
3- Cluster3
DFCS_Ref DFCS Referral 1- Reunifiedfostercare
case/Court-orderedreferral
(RCT eligible,if couple)
2- Familypreservation(closed
case)
3- SubstantiatedClosed
Investigation
4- UnsubstantiatedClosed
Investigation
5- ClosedFamilySupportCase
RelStat RelationshipStatus 1- Single
2- Married
3- Couple (>6mth)
4- Couple (<6mth)
ParStat ParentStatus 1- ExpectantParent
2- New Parent(child0-5)
3- Adoptive Parent
4- FosterParent
5- KinshipCaregiver
6- Fictive KinCaregiver
7- Other(text)
ProgElig Program Eligibility 1- Elevate
2- Elevate RCT
3- Elevate WeekendRetreat
4- TogetherWe Can
ProgID Program ID (fromnFORM,after
enrolled)
FAMILY ENGAGEMENT SUMMARY
(numeric,text,check
box needed,etc.)
QuantifiedResponses
Enroll_Typ EnrollmentType 1- Referral
2- Self-referred
3- RegisteredatCommunity
event
Enroll_RefDate Enrollment:Referral Date Numeric
(mm/dd/year)
Enroll_RefSrc Enrollment:Referral Source Text
Enroll_SelfRefDate Enrollment:Self-referredDate Numeric
(mm/dd/year)

Enroll_CE_Date Enrollment:Registeredat
CommunityeventDate
Enroll_CE_Met Enrollment:Registeredat
CommunityeventLocation/Person
Met
LM LetterMailed 0- No
1- Yes
2- N/A (WeekendRetreator
Self-referral)
LM_Date (IFYes) LetterMailedDate Numeric
(mm/dd/year)
InIntCall_Date Initial Intake Call Date Completed Numeric
(mm/dd/year)
InIntCall_Time Initial Intake Call Time Numeric(_:_ _
AM/PM)
InIntNav Initial Intake Phone Call Completed
by
Text
LM_HTR Hard to Reach LetterMailed 0- No; 1- Yes
LM_HTR_Date (IFYes) Hard to Reach LetterMailed
Date
LM_HTR_Nav (IFYes) Hard to Reach LetterMailed
Who Prepped/Mailed
LM_CO Close-OutLetterMailed 0- No; 1- Yes
LM_CO_Date (IFYes) Close-OutLetterMailed
Date
LM_CO_Nav (IFYes) Close-OutLetterMailed
Who Prepped/Mailed
PIV_Nav1 Navigator1 Text
PIV_Nav2 Navigator2 Text
PIV_OS_Date OriginallyScheduledDate Numeric
(mm/dd/year)
PIV_OS_Time OriginallyScheduledTime Numeric(_:_ _
AM/PM)
PIV_Date PIV CompletedDate Numeric
(mm/dd/year)
PIV_Time PIV CompletedTime Numeric(_:_ _
AM/PM)
PIV_XResch # of TimesRescheduled 0, 1, 2, 3+
PIV_Location Location 1- Phone (PIC)
2- Home (PIV)
3- Other
PIV_LocationOth Location- Other: Text
P1_ProgConsDate Program ConsentDate Numeric
(mm/dd/year)
P1_ResConsDate ResearchConsentDate Numeric
(mm/dd/year)

P1_CCWaivDate Childcare Waiver(if applicable) Date Numeric
(mm/dd/year)
P2_ProgConsDate Program ConsentDate Numeric
(mm/dd/year)
P2_ResConsDate ResearchConsentDate Numeric
(mm/dd/year)
P2_CCWaivDate Childcare Waiver(if applicable) Date Numeric
(mm/dd/year)
Hotel_Res Hotel RoomReserved 0- No; 1- Yes
CCare_Need Childcare Needed 0- No; 1- Yes
NA_Date NeedsAssessmentPhone Call
CompletedDate
(mm/dd/year)
NA_Time NeedsAssessmentPhone Call
CompletedTime
(_:_ _ AM/PM)
NA_Nav NeedsAssessmentNavigator Text
PAE1_Date PAE (ProgramAttendance and
Engagement) Session1:Date
(mm/dd/year)
P1_PAE1_Attend Session1:Attended 0- No; 1- Yes
P1_PAE1-FUDate Session1:Follow-upCall Date (mm/dd/year)
P2_PAE1Followup_Da
te
Session1:Follow-upCall Date (mm/dd/year)
PAE2_Date Session2:Date (mm/dd/year)
P1_PAE2_FUDate Session2:Follow-upCall Date (mm/dd/year)

EVALUATION ASSESSMENTS
(numeric,text,check
box needed,etc.)
QuantifiedResponses
Jimmy,is there anyway foryou to setup a reminderemail
that can be sentto the Clustercoordinatorinthe Evaluation
Assessmentssection?
P1_EA1_Typ (Evaluation) Assessment#1 1- Group
2- Home Visit
P1_EA1_SchDate Assessment#1 ScheduledDate (mm/dd/year)
P1_EA1_EndDate Assessment#1 CompletionDate (mm/dd/year)
P1_EA2_Typ Assessment#2 1- Group
2- Home Visit
P1_EA3_Typ Assessment#3 1- Group
2- Home Visit
P2_ EA1_Typ Assessment#1 1- Group
2- Home Visit
2- Home Visit
2- Home Visit
P1_nfm_AppChDate (nFORMAssessments)Applicant
Characteristic(AppCh) Date
(mm/dd/year)
P1_nfm_EntDate Entry Form Date (mm/dd/year)
P1_nfm_ExitDate ExitForm Date (mm/dd/year)
P2_nfm_AppChDate ApplicantCharacteristicDate (mm/dd/year)
P2_nfm_EntDate Entry Form Date (mm/dd/year)
P2_nfm_ExitDate ExitForm Date (mm/dd/year)
SECTION 1: PHONE CALL LOG AND NOTES

(numeric,text,check
box needed,etc.)
QuantifiedResponses
Call1_Part Phone Call 1- ParticipantCalled 1- Participant1
2- Participant2
Call1_Date Phone Call 1- Date Numeric
(mm/dd/year)
Call1_Time Phone Call 1- Time of Call Numeric(_:_ _
AM/PM)
Call1_Nav Phone Call 1- ProjectF.R.E.E.Staff
Name
Text
Call1_Nature Phone Call 1- Nature of Call 1- Initial Intake
2- PIV/PIC-related
3- Pre-Assessment
4- NeedsAssessment
5- Program reminder/follow-up
6- Post-Assessment
7- Other
Call1_NatureOth Phone Call 1- Nature of Call- Other Text
Call1_Result Phone Call 1- Resultof Call 1- No Answer/KeptRinging
2- Hang Up
3- Disconnected
4- Voice Message
5- Spoke to
6- Other
Call1_ResultWho Phone Call 1- Resultof Call- Spoke to Text
Call1_ResultOth Phone Call 1- Resultof Call- Other Text
Call1_FUNeed Phone Call 1- FollowUpNeeded 0- No; 1- Yes
Call1_Desc Phone Call 1- Yes(describe) Text
2- Participant2
(mm/dd/year)
AM/PM)
Name
Text
2- PIV/PIC-related
3- Pre-Assessment
4- Needs Assessment
6- Post-Assessment
7- Other
2- Hang Up

3- Disconnected
4- Voice Message
5- Spoke to
6- Other
Call2_FUNeed Phone Call 2- FollowUpNeeded 0- No; 1- Yes
2- Participant2
(mm/dd/year)
AM/PM)
Name
Text
2- PIV/PIC-related
3- Pre-Assessment
4- NeedsAssessment
6- Post-Assessment
7- Other
2- Hang Up
3- Disconnected
4- Voice Message
5- Spoke to
6- Other
Call3_FUNeed Phone Call 3- FollowUp Needed 0- No; 1- Yes
FORM 2A: CONTACT INFORMATION
Variable Name Field Question Response options
(numeric,text,check
box needed,etc.)
QuantifiedResponses
P1_PriCont PrimaryContact:Participant1
(Initial Applicant)
0- No; 1- Yes
P1_LName Last Name Text
P1_FName FirstName Text
P1_MidIn Middle Initial Text(one letter)
P1_StrAd StreetAddress Text/Numeric
P1_Apt Apartment/Unit# Text/Numeric

P1_Cnty County Text(Dropdown-see
Region5 County
Table)
P1_City City Text(Dropdown- See
Citytable percounty)
P1_State State (GA)
P1_Zip ZipCode Numeric
P1_CellPh Cell Phone
P1_CellVoice OK to leave voicemail ortext
message?
0- No; 1- Yes
P1_HmPh Home Phone
P1_HmVoice OK to leave voicemail ortext
message?
0- No; 1- Yes
P1_AltPh Alternate Phone
P1_AltVoice OK to leave voicemail ortext
message?
0- No
1- Yes
P1_PrefCont PreferredContact 1- Cell Phone
2- Home Phone
3- Alternate Phone
P1_BestCallDay BestDay(s) to Call 1- Mon
2- Tues
3- Wed
4- Thur
5- Fri
P1_BestCallTime BestTime(s) toCall 1- 10AM-12PM
2- 12PM-3PM
3- 3PM-6PM
4- 6PM-8PM
P1_Email Email Text/Numeric
P1_EmailInfo OK to email withclassinformation 0- No; 1- Yes
P2_PriCont PrimaryContact:Participant2 0- No; 1- Yes
P2_LName Last Name Text
P2_FName FirstName Text
P2_MidIn Middle Initial Text(one letter)
P2_P1Address Same addressas P1 0- No; 1- Yes
P2_StrAd StreetAddress Text/Numeric
P2_Apt Apartment/Unit# Text/Numeric
P2_Cnty County Text(Dropdown-see
Region5 County
Table)
P2_City City Text(Dropdown- See
Citytable percounty)
P2_State State (GA)
P2_Zip ZipCode Numeric
P2_CellPh Cell Phone

P2_CellVoice OK to leave voicemail ortext
message?
0- No; 1- Yes
P2_HmPh Home Phone
P2_HmVoice OK to leave voicemail ortext
message?
0- No; 1- Yes
P2_AltPh Alternate Phone
P2_AltVoice OK to leave voicemail ortext
message?
0- No; 1- Yes
P2_PrefCont PreferredContact 1- Cell Phone
2- Home Phone
3- Alternate Phone
P2_BestCallDay BestDay(s) to Call 1- Mon
2- Tues
3- Wed
4- Thur
5- Fri
P2_BestCallTime BestTime(s) toCall 1- 10AM-12PM
2- 12PM-3PM
3- 3PM-6PM
4- 6PM-8PM
P2_Email Email Text/Numeric
P2_EmailInfo OK to email withclassinformation Check Boxes:
Yes/No
0- No; 1- Yes
P1_EmerConNm EmergencyContactInformation:Full
Name
P1_EmerConPh EmergencyContactInformation:
Phone Number
P1_EmerConRel EmergencyContactInformation:
Relationshiptoyou?
P2_EmerConNm EmergencyContactInformation:Full
Name
P2_EmerConPh EmergencyContactInformation:
Phone Number
P2_EmerConRel EmergencyContactInformation:
Relationshiptoyou?
FORM 2B: ELIGIBILITY INFORMATION
(numeric,text,check
box needed,etc.)
QuantifiedResponses
I. Relationship Status
RelStat Are you currentlyina committed
couple relationship?
0- No; 1- Yes
RelStatTyp IF YES: How wouldyoudescribe your
currentcouple relationship?
1- Dating
2- Engaged
3- Married
4- Other
RelStatTyp_Oth Currentcouple relationship- Other Text

LenMar_Yr If married:How longhave youbeen
married(years)?
Numeric
LenMar_Mth If married:How longhave youbeen
married(months)?
Numeric
LenRel_Yr In total,how longhave youbeen
withyourpartner (years)?
Numeric
LenRel_Mth In total,howlonghave youbeen
withyourpartner (months)?
Numeric
LvTg Do youand your partnercurrently
live together?
0- No; 1- Yes
II. Parenting Status
HaveCh Excludingchildreninfostercare,
howmany childrendoyou(and/or
your partner) have?
Numeric
YChAge_Yr Excludingchildreninfostercare,
whatis the age of your (and/oryour
partner’s) youngestchild (years)?
Numeric
YChAge_Mth Excludingchildreninfostercare,
partner’s) youngestchild(months)?
Numeric
YChSex YoungestChildGender 0- Female
1- Male
YChRel YoungestChildRelationship 1- Biological
2- Adopted
3- Stepchild
4- Other
YChRel_Oth YoungestChild Relationship- Other Text
YCh_Part YoungestChild- Whose 1- Part. 1
2- Part. 2
3- Both
OChAge_Yr Excludingchildreninfostercare,
partner’s) oldestchild (years)?
Numeric
OChAge_Mth Excludingchildreninfostercare,
partner’s) oldestchild(months)?
Numeric
OChSex OldestChildGender 0- Female
1- Male
OChRel OldestChildRelationship 1- Biological
2- Adopted
3- Stepchild
4- Other
OChRel_Oth OldestChildRelationship- Other Text
OCh_Part OldestChild- Whose 1- Part. 1
2- Part. 2
3- Both

CurrPreg Are you (oryour partner) currently
pregnant?
0- No; 1- Yes
FPar Are you an approvedandcurrently
active (i.e.,eligibleforplacement)
fosterparent?
0- No; 1- Yes
III. Foster Caregiver Status
Num_FCh In the past 12 months,how many
childreninfostercare have you
cared for?
Numeric
CurrNum_FCh Currentlyhowmanychildrenin
fostercare are livinginyourhome?
Numeric
LenFPar_Yr How longhave youbeenan
approvedfostercaregiver(years)?
Numeric
LenFPar_Mth How longhave youbeenan
approvedfostercaregiver(months)?
Numeric
AgencyCertU Whichagencyare you certified
under?
1- DFCS
2- CPA
3- Other
AgencyCertU_Oth Agencycertifiedunder- Other Text
FPar_Reg FosterCaregiverregisteringfor
weekendretreat?
0- No; 1- Yes
Both_Attend IF YES: Are both youand your
partnerplanningtoattend?
0- No; 1- Yes
Prov_CCard Wouldyoube able toprovide a
creditcard to reserve yourhotel
room?
0- No; 1- Yes
CCare_Need From yourapplicationIsee you
wanted/neededtobringyour
childrentothe retreat,isthis
correct?
0- No; 1- Yes
CCare_ChAges IF Yes:Agesof each childyouwould
needtobringwithyou:
FORM 2C-1: RELATIONSHIP SAFETY SCREENING (PARTNER)
(numeric,text,check
box needed,etc.)
QuantifiedResponses
P1_2C1_RSS1 In general,howwouldyoudescribe
your relationship?
0- No tension
1- Some tension
2- A lotof tension
P1_2C1_RSS2 Do youand your partnerworkout
argumentswith…
0- No difficulty
1- Some difficulty
2- Great difficulty
P1_2C1_RSS3 Do argumentseverresultinyou
feelingdownorbadaboutyourself?
0- Never
1- Sometimes
2- Often
P1_2C1_RSS4 Do argumentseverresultinhitting,
kickingorpushing?
0- Never
1- Sometimes

2- Often
P1_2C1_RSS5 Do youeverfeel frightenedbywhat
your partnersaysor does?
0- Never
1- Sometimes
2- Often
your relationship?
0- No tension
1- Some tension
2- A lotof tension
argumentswith…
0- No difficulty
1- Some difficulty
2- Great difficulty
0- Never
1- Sometimes
2- Often
kickingorpushing?
0- Never
1- Sometimes
2- Often
0- Never
1- Sometimes
2- Often
FORM 2C-2: RELATIONSHIP SAFETY SCREENING (CO-
PARENT)
(numeric,text,check
box needed,etc.)
QuantifiedResponses
your relationship?
0- No tension
1- Some tension
2- A lotof tension
argumentswith…
0- No difficulty
1- Some difficulty
2- Great difficulty
0- Never
1- Sometimes
2- Often
kickingorpushing?
0- Never
1- Sometimes
2- Often
0- Never
1- Sometimes
2- Often
FORM 2D: ENGAGEMENT WITH DFCS/ADDITIONAL SOCIAL
SERVICES
(numeric,text,check
box needed,etc.)
QuantifiedResponses
SNAP_Recv FoodStampsor Supplemental
Nutritional Assistance Program
0- No
1- Yes Past
2- Yes Current

WIC_Recv Women,Infants, andChildren 0- No
1- Yes Past
2- Yes Current
TANF_Recv TemporaryAssistance forNeedy
Families
0- No
1- Yes Past
2- Yes Current
Medicaid_Recv Medicaid 0- No
1- Yes Past
2- Yes Current
OthDFCSSer_Recv OtherservicesfromDFCSor the
HealthDepartment
0- No
1- Yes Past
2- Yes Current
CurrOC_FC DFCS OpenCase:FosterCare 0- No
1- Yes Past
2- Yes Current
CurrOC_FamPres DFCS OpenCase:Family
Preservation
0- No
1- Yes Past
2- Yes Current
CurrOC_Investig DFCS OpenCase:OpenDFCS
Investigation
0- No
1- Yes Past
2- Yes Current
CurrOC_FamSup DFCS OpenCase:FamilySupport
Case
0- No
1- Yes Past
2- Yes Current
CurrOC_ActCrtInv DFCS OpenCase:Active Court
Involvement
0- No
1- Yes Past
2- Yes Current
CurrOC_Oth DFCS OpenCase:Other 0- No
1- Yes Past
2- Yes Current
CMngr_Nm DFCS Case Manager Name Text
CMngr_Ph DFCS Case Manager Phone Number Text
FrstStps_Recv FirstSteps 0- No
1- Yes Past
2- Yes Current
ParAsTeach_Recv Parentsas Teachers 0- No
1- Yes Past
2- Yes Current
HFamGa_Recv HealthyFamiliesGeorgia 0- No
1- Yes Past
2- Yes Current
GenHmSer_Recv General counseling,parenting,early
intervention,orothertypesof home
services
0- No
1- Yes Past
2- Yes Current
HdStrt_Recv Early HeadStart or Head Start 0- No
1- Yes Past
2- Yes Current

OthHmVSer_Recv Otherservice where someone
comesto your home
0- No
1- Yes Past
2- Yes Current
SSI_Recv Supplemental SecurityIncome 1- No
2- Yes Past
3- Yes Current
SSDI_Recv Social SecurityDisabilityInsurance 1- No
2- Yes Past
3- Yes Current
UnempIns_Recv UnemploymentInsurance 1- No
2- Yes Past
3- Yes Current
VITA_Recv VoluntaryIncome Tax Assistance 1- No
2- Yes Past
3- Yes Current
FreeFinCnsl_Recv Free financial Counseling 1- No
2- Yes Past
3- Yes Current
HousEdc_Recv HousingEducation 1- No
2- Yes Past
3- Yes Current
HousVouch_Recv Housingchoice voucher 1- No
2- Yes Past
3- Yes Current
HousAthy_Recv HousingAuthority 1- No
2- Yes Past
3- Yes Current
FinAssist_Recv Financial Assistance 1- No
2- Yes Past
3- Yes Current
FreeCCare_Recv Free or subsidizedchildcare
resources
1- No
2- Yes Past
3- Yes Current
FreeEmpSer_Recv Free jobcoachingor employment
services
1- No
2- Yes Past
3- Yes Current
OthFinSer_Recv Otherfinancial supportservice 1- No
2- Yes Past
3- Yes Current
ProjSafe_Recv ProjectSafe 1- No
2- Yes Past
3- Yes Current
UGAExt_Recv UGA Extension 1- No
2- Yes Past
3- Yes Current
OthAddSer_Recv Othersupportservice 1- No
2- Yes Past

3- Yes Current
GenNeeds What, if any,are potential obstacles
that mightpreventyouandyour
familyfromparticipatinginthis
program?
Text
ExistingRes What, if any,are existingresources
that mightassistyouand your
familyinparticipatinginthis
program?
Text
FORM 3A: RELATIONSHIP AND FAMILY INFORMATION
(numeric,text,check
box needed,etc.)
QuantifiedResponses
Participant 1
P1_MarStat Currentlymarried 0- No; 1- Yes
P1_RelHist_SPar If single:Have youeverbeen
married?
0- No; 1- Yes
P1_XMar All:Howmany times(if married:
includingyourcurrentmarriage),
have youbeenmarried?
Numeric
P1_NumAdH How manyadults,includingyourself,
live inthe home at leasthalf of the
time?
Numeric
P1_NumChH How manychildrenunderthe age of
18 are livinginthe house atleast
half of the time?
Numeric
P1_NumBioCh_Cpl If couple:Howmany biological
childrendoyouand yourcurrent
partnershare?
Numeric
P1_NumBioCh_SPar If single:Howmanybiological
childrendoyouhave?
Numeric
P1_NumAdpCh_Cpl If couple:Howmany adoptive
partnershare?
Numeric
P1_NumAdpCh_SPar If single:Howmanyadoptive
childrendoyoucurrentlyhave?
Numeric
P1_NumChPrvRelH How manychildrendoyouhave
froma previous relationship living
withyouin the household?
Numeric
P1_NumChPrvRelNH How manychildrendoyouhave
fromyour previous relationships
whoare not livinginthe household?
Numeric
P1_Preg Expecting/Pregnant 0- No; 1- Yes
P1_FrstPreg If ExpectantParent:Is thisyourfirst
child?
0- No; 1- Yes
P1_LenPreg If ExpectantParent: Numeric(2digitsfor
MTHS)

How manymonthsare you(your
partner) intoyourpregnancy?
P1_CaredFCh In the past 12 months,have you
(andyour partner) caredfor a child
infostercare?
0- No; 1- Yes
P1_NumFCh If FosterCaregiver:Inthe past 12
months,howmanychildreninfoster
care have youcared for?
Numeric
P1_CurrNumFCh If FosterCaregiver:Currentlyhow
manychildreninfostercare are
livinginyourhome?
Numeric
P1_LenFPar_Yr If FosterCaregiver:How longhave
youbeenan approvedfoster
caregiver(years)?
Numeric
P1_LenFPar_Mth If FosterCaregiver:How longhave
youbeenan approvedfoster
caregiver(months)?
Numeric
Participant 2
P2_MarStat Currentlymarried 0- No; 1- Yes
P2_XMar All:Howmany times(if married:
includingyourcurrentmarriage),
have youbeenmarried?
Numeric
P2_NumAdH How manyadults,includingyourself,
live inthe home at leasthalf of the
time?
Numeric
P2_NumChH How manychildrenunderthe age of
18 are livinginthe house atleast
half of the time?
Numeric
P2_NumBioCh_Cpl If couple:Howmany biological
partnershare?
Numeric
P2_NumAdopCh_Cpl If couple:Howmany adoptive
partnershare?
Numeric
P2_NumChPrvRelH How manychildrendoyouhave
froma previous relationship living
withyouin the household?
Numeric
P2_NumChPrvRelNH How manychildrendoyouhave
fromyour previous relationships
whoare not livingwithyouinthe
household?
Numeric
P2_Preg Expecting/Pregnant 0- No; 1- Yes
P2_FrstPreg If ExpectantParent:
Is thisyourfirstchild?
0- No; 1- Yes
P2_LenPreg If ExpectantParent:
How manymonthsare you(your
partner) intoyourpregnancy?
Numeric(2digitsfor
MTHS)

P2_CaredFCh In the past 12 months,have you
(andyour partner) caredfor a child
infostercare?
0- No; 1- Yes
P2_NumFCh In the past 12 months,how many
childreninfostercare have you
cared for?
Numeric
P2_CurrNumFCh Currentlyhowmanychildrenin
fostercare are livinginyourhome?
Numeric
P2_LenFPar_Yr How longhave youbeenan
approvedfostercaregiver(years)?
Numeric
P2_LenFPar_Mth How longhave youbeenan
approvedfostercaregiver(months)?
Numeric
FORM 3B: ABOUT YOU
(numeric,text,check
box needed,etc.)
QuantifiedResponses
Part1 Participant1 1- Participant1
2- Participant2
P1_DOB Date of Birth
P1_Age Age (inyears) Numeric
P1_Sex What isyour gender? 0- Female
1-Male
2- Other
P1_SexOth GenderOther Text
P1_SexOr How wouldyoudescribe yoursexual
orientation?
1- Heterosexual
2- Gay/Lesbian
3- Bisexual
4- Other
P1_SexOrOth Sexual orientationOther Text
P1_Race How wouldyoudescribe yourrace? 1- White/Caucasian
2- African-American/Black
3- Asian-American
4- Native-American/Alaskan
Native
5- Native Hawaiian/OtherPacific
Islander
6- Other
P1_RaceOth Race Other Text
P1_Eth How wouldyoudescribe your
ethnicity?
1- Non-Hispanic
2- Hispanic
3- Other
P1_EthOth EthnicityOther Text
P1_Student Are you currentlyinschool or
college?
0- No
1- Yes,Full-time
2- Yes,Part-time
P1_Edc What isthe highestlevel of
educationyouhave completed?
1- High School General
EducationDevelopment

2- Attendedhighschool,butdid
not earndiploma
3- High school diploma
4- Vocational/ technical school
certification
5- Some college butnodegree
completion
6- Associate’sdegree
7- Bachelor’sdegree
8- Master’s degree/Advanced
degree
P1_EmpStat What isyour currentemployment
status?
1- Not currentlyemployed
2- Full-time (35+hours/week)
3- Part-time (1-34 hours/week)
4- Temporary,occasional,
seasonal,oroddjobsfor pay
P1_UnempStat If unemployed,are you: 1- Activelylookingforwork
2- Disabled
3- Retired
4- None of the above
P1_EmpBen If employed,doyouhave benefits
throughyour jobsuch as paid
vacation,sickleave,orlife
insurance?
0- No
1- Yes
2- I don’tknow
P1_Occp If employed,whatisyour
occupation?
Text
P1_HH_AnnInc What isyour total household annual
income (if marriedorliving
together)?
1- Less than$7,000
2- $7,000 – $13,999
3- $14,000 – $24,999
4- $25,000 – $39,999
5- $40,000 – $74,999
6- $75,000 – $99,999
7- $100,000+
P1_Last30_Inc In the past 30 days,how much
moneydidyoumake?
1- Less than$500
2- $500 - $1,000
3- $1,001 - $2,000
4- $2,001 - $3,000
5- $3,001 - $4,000
6- $4,001 - $5,000
7- More than $5,000
P1_LvStat What isyour currentliving
situation?
1- Home Owner
2- Rent
3- Other
P1_LvStatOth LivingsituationOther Text
P1_DietRes Do youhave any dietary
restrictions?
0- No
1- Vegetarian
2- Vegan

3- Nut Allergy
4- Other
P1_DietResOth DietaryrestrictionsOther Text
P1_Transp Do youhave access to
transportationthatwouldallow you
and yourfamilytoattendclassesfor
thisprogram?
0- No; 1- Yes
P1_SNeed Do youhave any special needsthat
impairyourdailyfunctioning?
0- No
1- Have a physical disability
2- Have a learningdisability
3- Have a developmental
disability
4- Have beendiagnosedwitha
mental illness
5- Have a medical illness
6- Other
P1_SNeedOth Special needsOther Text
P1_GNeed Whichof the following,if any,do
youfeel describe yourgreatest
needsrightnow?
1- Unstable housing
2- Rent/mortgage assistance
3- Immediate shelter
4- Utilitiesassistance
5- Accessto phone
6- Connectiontoeducational
resources
7- Unemployment
8- Childcare
9- Career/vocational training
10- Food
11- Clothing
12- Accessto medical care
13- Social support
14- Physical safety
15- Accessto mental health
treatment
16- Accessto transportation
17- Child(ren)’sdevelopmental
needs
P2 Participant2 1- Participant1
2- Participant2
P2_DOB Date of Birth
P2_Age Age (inyears) Numeric
P2_Sex What isyour gender? 0- Female
1-Male
2- Other
P2_SexOth GenderOther Text
P2_SexOr How wouldyoudescribe yoursexual
orientation?
1- Heterosexual
2- Gay/Lesbian

3- Bisexual
4- Other
P2_SexOrOth Sexual orientationOther Text
P2_Race How wouldyoudescribe yourrace? 1- White/Caucasian
3- Asian-American
Native
Islander
6- Other
P2_RaceOth Race Other Text
P2_Eth How wouldyoudescribe your
ethnicity?
1- Non-Hispanic
2- Hispanic
3- Other
P2_EthOth EthnicityOther Text
P2_Student Are you currentlyinschool or
college?
0- No
1- Yes,Full-time
2- Yes,Part-time
P2_Edc What isthe highestlevel of
educationyouhave completed?
1- High School General
EducationDevelopment
2- Attendedhighschool,butdid
not earndiploma
3- High school diploma
4- Vocational/ technical school
certification
5- Some college butnodegree
completion
6- Associate’sdegree
7- Bachelor’sdegree
8- Master’s degree/Advanced
degree
P2_EmpStat What isyour currentemployment
status?
1- Not currentlyemployed
2- Full-time (35+hours/week)
3- Part-time (1-34 hours/week)
4- Temporary,occasional,
seasonal,oroddjobsfor pay
P2_UnempStat If unemployed,are you: 1- Activelylookingforwork
2- Disabled
3- Retired
4- None of the above
P2_EmpBen If employed,doyouhave benefits
throughyour jobsuch as paid
vacation,sickleave,orlife
insurance?
0- No
1- Yes
2- I don’tknow
P2_Occp If employed,whatisyour
occupation?
Text

P2_HH_AnnInc What isyour total household annual
income (if marriedorliving
together)?
1- Less than$7,000
2- $7,000 – $13,999
3- $14,000 – $24,999
4- $25,000 – $39,999
5- $40,000 – $74,999
6- $75,000 – $99,999
7- $100,000+
P2_Last30_Inc In the past 30 days,how much
moneydidyoumake?
1- Less than$500
2- $500 - $1,000
3- $1,001 - $2,000
4- $2,001 - $3,000
5- $3,001 - $4,000
6- $4,001 - $5,000
7- More than $5,000
P2_LvStat What isyour currentliving
situation?
1- Home Owner
2- Rent
3- Other
P2_LvStatOth LivingsituationOther Text
P2_DietRes Do youhave any dietary
restrictions?
0- No
1- Vegetarian
2- Vegan
3- Nut Allergy
4- Other
P2_DietResOth DietaryrestrictionsOther Text
P2_Transp Do youhave access to
transportationthatwouldallow you
and yourfamilytoattendclassesfor
thisprogram?
0- No; 1- Yes
P2_SNeed Do youhave any special needsthat
impairyourdailyfunctioning?
0- No
1- Have a physical disability
2- Have a learningdisability
3- Have a developmental
disability
4- Have beendiagnosedwitha
mental illness
5- Have a medical illness
6- Other
P2_SNeedOth Special needsOther Text
P2_GNeed Whichof the following,if any,do
youfeel describe yourgreatest
needsrightnow?
1- Unstable housing
2- Rent/mortgage assistance
3- Immediate shelter
4- Utilitiesassistance
5- Accessto phone
6- Connectiontoeducational
resources
7- Unemployment
8- Childcare

9- Career/vocational training
10- Food
11- Clothing
12- Accessto medical care
13- Social support
14- Physical safety
15- Accessto mental health
treatment
16- Accessto transportation
17- Child(ren)’sdevelopmental
needs
FORM 3C-1: YOUR RELATIONSHIP EXPERIENCES (PARTNER)
(numeric,text,check
box needed,etc.)
QuantifiedResponses
P1_3C1_YE1 How safe doyou feel inyourcurrent
relationship?
1, 2, 3, 4, 5, 6, 7, 8, 9, 10
P1_3C1_YE2 My partnerneveradmitswhenshe
or he is wrong.
1, 2, 3, 4, 5
P1_3C1_YE3 My partnerisunwillingtoadaptto
my needsandexpectations.
1, 2, 3, 4, 5
P1_3C1_YE4 My partnerismore insensitive than
caring.
1, 2, 3, 4, 5
P1_3C1_YE5 I am oftenforcedto sacrifice my
ownneedstomeetmy partner's
needs.
1, 2, 3, 4, 5
P1_3C1_YE6 My partnerrefusestotalkabout
problemsthatmake himor herlook
bad.
1, 2, 3, 4, 5
P1_3C1_YE7 My partnerwithholdsaffection
unlessitwouldbenefitherorhim.
1, 2, 3, 4, 5
P1_3C1_YE8 It ishard to disagree withmy
partnerbecause she or he gets
angry.
1, 2, 3, 4, 5
P1_3C1_YE9 My partnerresentsbeing
questionedaboutthe wayhe or she
treatsme.
1, 2, 3, 4, 5
P1_3C1_YE10 My partnerbuildshimself orherself
up by puttingme down.
1, 2, 3, 4, 5
P1_3C1_YE11 My partnerretaliateswhenI
disagree withhimorher.
1, 2, 3, 4, 5
P1_3C1_YE12 My partnerisalwaystryingto
change me.
1, 2, 3, 4, 5
P1_3C1_YE13 My partnerbelieveshe orshe has
the right to force me to do things.
1, 2, 3, 4, 5
P1_3C1_YE14 My partneristoo possessiveor
jealous.
1, 2, 3, 4, 5

P1_3C1_YE15 My partnertriestoisolate me from
familyandfriends.
1, 2, 3, 4, 5
P1_3C1_YE16 Sometimesmypartnerphysically
hurts me.
1, 2, 3, 4, 5
P2_3C1_YE1 How safe doyou feel inyourcurrent
relationship?
1, 2, 3, 4, 5, 6, 7, 8, 9, 10
P2_3C1_YE2 My partnerneveradmitswhenshe
or he is wrong.
1, 2, 3, 4, 5
P2_3C1_YE3 My partnerisunwillingtoadaptto
my needsandexpectations.
1, 2, 3, 4, 5
P2_3C1_YE4 My partnerismore insensitive than
caring.
1, 2, 3, 4, 5
P2_3C1_YE5 I am oftenforcedtosacrifice my
ownneedstomeetmy partner's
needs.
1, 2, 3, 4, 5
P2_3C1_YE6 My partnerrefusestotalkabout
bad.
1, 2, 3, 4, 5
P2_3C1_YE7 My partnerwithholdsaffection
1, 2, 3, 4, 5
P2_3C1_YE8 It ishard to disagree withmy
partnerbecause she or he gets
angry.
1, 2, 3, 4, 5
P2_3C1_YE9 My partnerresentsbeing
treatsme.
1, 2, 3, 4, 5
P2_3C1_YE10 My partnerbuildshimself orherself
up byputtingme down.
1, 2, 3, 4, 5
P2_3C1_YE11 My partnerretaliateswhenI
1, 2, 3, 4, 5
P2_3C1_YE12 My partnerisalwaystryingto
change me.
1, 2, 3, 4, 5
P2_3C1_YE13 My partnerbelieveshe orshe has
1, 2, 3, 4, 5
P2_3C1_YE14 My partneristoo possessiveor
jealous.
1, 2, 3, 4, 5
P2_3C1_YE15 My partnertriestoisolate me from
familyandfriends.
1, 2, 3, 4, 5
P2_3C1_YE16 Sometimesmypartnerphysically
hurts me.
1, 2, 3, 4, 5
FORM 3C-2: YOUR RELATIONSHIP EXPERIENCES (CO-
PARENT)
(numeric,text,check
box needed,etc.)
QuantifiedResponses

P1_3C2_YE1 How safe doyou feel inyour
relationship withyourchild(ren)’s
otherparent?
1, 2, 3, 4, 5, 6, 7, 8, 9, 10
P1_3C2_YE2 My co-parentneveradmitswhen
she or he iswrong.
1, 2, 3, 4, 5
P1_3C2_YE3 My co-parentisunwillingtoadapt
to my needsandexpectations.
1, 2, 3, 4, 5
P1_3C2_YE4 My co-parentismore insensitive
than caring.
1, 2, 3, 4, 5
P1_3C2_YE5 I am oftenforcedtosacrifice my
ownneedstomeetmy co-parent's
needs.
1, 2, 3, 4, 5
P1_3C2_YE6 My co-parentrefusestotalkabout
bad.
1, 2, 3, 4, 5
P1_3C2_YE7 My co-parentwithholdsaffection
1, 2, 3, 4, 5
P1_3C2_YE8 It ishard to disagree withmy co-
parentbecause she or he getsangry.
1, 2, 3, 4, 5
P1_3C2_YE9 My co-parentresentsbeing
treatsme.
1, 2, 3, 4, 5
P1_3C2_YE10 My co-parentbuildshimself or
herself upbyputtingme down.
1, 2, 3, 4, 5
P1_3C2_YE11 My co-parentretaliateswhenI
1, 2, 3, 4, 5
P1_3C2_YE12 My co-parentisalwaystryingto
change me.
1, 2, 3, 4, 5
P1_3C2_YE13 My co-parentbelieveshe orshe has
1, 2, 3, 4, 5
P1_3C2_YE14 My co-parentistoopossessiveor
jealous.
1, 2, 3, 4, 5
P1_3C2_YE15 My co-parenttriestoisolate me
fromfamilyandfriends.
1, 2, 3, 4, 5
P1_3C2_YE16 Sometimesmy co-parentphysically
hurts me.
1, 2, 3, 4, 5
FORM 3D1: RESIDENT CHILD INFORMATION
Variable Name Question Response options
(numeric,text,check
box needed,etc.)
QuantifiedResponses
RC1 ResidentChild#1(RC2 = Resident
Child#2)
Numeric
RC1_LName Last Name Text
RC1_FName FirstName Text
RC1_MidIn Middle Initial Text(one letter)
RC1_Part Whose childisthis? 1- Participant1
2- Participant2

3- Both
4- Fostered
RC1_Rel What isyour relationshiptothis
child?
1- Biological Parent
2- Step-Parent
3- Adoptive Parent
4- FosterParent
5- KinshipCare Provider
RC1_DOB Date of Birth
RC1_Age_Yr Age (years)
RC1_Age_Mth Age (months)
RC1_Sex Child’sSex 0- Female
1- Male
2- Other
RC1_SexOth Child’sSex Other Text
RC1_ Race How wouldyoudescribe yourchild’s
race?
1- White/Caucasian
3- Asian-American
Native
Islander
6- Other
RC1_RaceOth Race Other Text
RC1_Eth How wouldyoudescribe yourchild’s
ethnicity?
1- Non-Hispanic
2- Hispanic
3- Other
RC1_EthOth EthnicityOther Text
RC1_Grade What grade is yourchildcurrently
in?
-1- Pre-K
0- Kindergarten
1- 1st
2- 2nd
3- 3rd
4- 4th
5- 5th
6- 6th
7- 7th
8- 8th
9- 9th
10- 10th
11- 11th
12- 12th
RC1_HIns Doesyour childhave health
insurance?
0- No
1- Yes
RC1_HInsTyp IF YES, whatkindof healthinsurance
doesyourchildhave?
1- Medicaid
2- PeachCare forKids
3- Through employer

4- Other
RC1_HInsTyp_Oth HealthInsurance Type Other Text
RC1_SNeed Doesyour childhave anyspecial
needs?
0- No
1- Has a physical disability
2- Has a developmental
disability
3- Has a medical illness
4- Has a learningdisability
5- Has an individualized
EducationPlan(IEP)
6- Strugglestomake good
grades
7- Has beendiagnosedwitha
mental illness
8- Other
RC1_SNeedOth Special NeedsOther Text
RC1_NRP_Have Doesthischildhave a parentwho
doesnotlive inthe home?
0- No; 1- Yes
RC1_NRP_DPW On average,howmanydaysper
weekdoesthe non-residentparent
see thischild?
1, 2, 3, 4, 5, 6, 7
RC1_NRP_WPM How manyweekendspermonth
doesthe non-residentparentsee
thischild?
0- 0
1- 1
2- 2
3- 3
4- Every
RC1_NRP_Consult How oftendoyouconsultwiththe
non-residentparentonmatters
relatingtothischild?
1- Most of the time
2- Some of the time
3- Seldom
4- Never
RC1_NRP_ContFin Doesthe non-residentparent
contribute financiallytosupportfor
thischild?
0- No; 1- Yes
RC1_TimeHH_Yr What isthe lengthof time thischild
has spentinyourhousehold(years)?
Numeric
RC1_TimeHH_Mth What isthe lengthof time thischild
has spentinyourhousehold
(months)?
Numeric
RC1_P1_Rel What isyour (P1) relationshiptothis
child?
1- FosterParent
2- Grandmother
3- Grandfather
4- Aunt
5- Uncle
6- Niece
7- Nephew
8- Sister
9- Brother

10- Cousin
11- FamilyFriend
12- Other
RC1_P1_RelOth P1 relationshiptothischild Other Text
RC1_P2_Rel What isyour (P2) relationshiptothis
child?
CheckBoxes:
FosterParent,
Grandmother,
Grandfather,
Aunt,Uncle,
Niece,Nephew,
Sister,Brother,
Cousin,Family
Friend,
Other(textbox)
1- FosterParent
2- Grandmother
3- Grandfather
4- Aunt
5- Uncle
6- Niece
7- Nephew
8- Sister
9- Brother
10- Cousin
11- FamilyFriend
12- Other
RC1_P2_RelOth P2 relationshiptothischild Other Text
RC1_P1_Adopt If this childwere free tobe legally
adopted,wouldyou(P1) planto
adoptthischild?
0- No
1- Yes
2- I don’tknow
RC1_P2_Adopt If this childwere free tobe legally
adopted,wouldyou(P2) planto
adoptthischild?
0- No
1- Yes
2- I don’tknow
RC1_Attend To attendthe ProjectF.R.E.E.
program wouldyouneedtobring
thischildwithyou?
0- No; 1- Yes
RC1_DietRes Doesyour childhave anydietary
restrictions?
0- No
1- Vegetarian
2- Vegan
3- Nut allergy
4- Dairy allergy
5- Other
RC1_DietResOth DietaryRestrictionsOther Text
RC1_Notes Is there anythingelse youwouldlike
to share that wouldbe helpful to
our childcare providers?
Text
RC1_CarSeat Do youhave access to a car seator
boosterseatfor yourchild?
0- No; 1- Yes
FORM 3D2: NON-RESIDENT CHILD INFORMATION
(numeric,text,check
box needed,etc.)
QuantifiedResponses
NRC1 Non-ResidentChild#1(NRC2 = Non-
ResidentChild#2)
Numeric
NRC1_LName Last Name Text
NRC1_FName FirstName Text
NRC1_MidIn Middle Initial Text(one letter)

NRC1_Resp Whose childisthis? 1- Participant1
2- Participant2
NRC1_Rel What isyour relationshiptothis
child?
1- Biological Parent
2- Step-Parent
3- Adoptive Parent
NRC1_DOB Date of Birth Numeric
NRC1_Age_Yr Age (years) Numeric
NRC1_Age_Mth Age (months)
NRC1_Sex Child’sSex 0- Female
1- Male
2- Other
NRC1_SexOth Child’sSex Other Text
NRC1_ Race How wouldyoudescribe yourchild’s
race?
1- White/Caucasian
3- Asian-American
Native
Islander
6- Other
NRC1_RaceOth Child’sRace Other Text
NRC1_Eth How wouldyoudescribe your
ethnicity?
1- Non-Hispanic
2- Hispanic
3- Other
NRC1_EthOth Child’sEthnicityOther Text
NRC1_Grade What grade is yourchildcurrently
in?
-1- Pre-K
0- Kindergarten
1- 1st
2- 2nd
3- 3rd
4- 4th
5- 5th
6- 6th
7- 7th
8- 8th
9- 9th
10- 10th
11- 11th
12- 12th
NRC1_HIns Doesyour childhave health
insurance?
0- No; 1- Yes
NRC1_HInsTyp If yes,what kindof healthinsurance
doesyourchildhave?
1- Medicaid
2- PeachCare forKids
3- Through employer
4- Other
NRC1_HInsTyp_Oth HealthInsurance Type Other Text

NRC1_SNeed Doesyour childhave anyspecial
needs?
0- No
1- Has a physical disability
2- Has a developmental
disability
3- Has a medical illness
4- Has a learningdisability
5- Has an individualized
EducationPlan(IEP)
6- Strugglestomake good
grades
7- Has beendiagnosedwitha
mental illness
8- Other
NRC1_SNeedOth Special NeedsOther Text
NRC1_DPW On average,howmanydaysper
weekdoyousee thischild?
1, 2, 3, 4, 5, 6, 7
NRC1_WPM How manyweekendspermonthdo
yousee thischild?
0- 0
1- 1
2- 2
3- 3
4- Every
NRC1_PRP_Consult How oftendoyouconsultwiththe
primary residentialparenton
mattersrelatingtothischild?
1- Most of the time
2- Some of the time
3- Seldom
4- Never
NRC1_ContFin Do youcontribute financiallyto
supportfor thischild?
0- No; 1- Yes

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