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Survey for Youth and Family Resource Centers and Parent/Teacher Home Visitation Project
This assessment is to be administered by trained Youth and Family Resource Center (YFRC) social workers or interns and Parent-Teacher Home Visitation (PTHV) teachers.
YFRC social workers/interns and PTHV teachers will complete the assessment at whatever point in time they feel confident that an accurate response can be recorded.
Responses to Question 1 and 2 should be based on interpretations of the information that has been shared over time by the student being assessed. For Question 3 the social workers/interns and teachers will record the student’s and caregiver’s ideas as well as their own.
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| Student Identification Number: | | |
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| Person Completing the Survey: | | |
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| Please enter the date you completed the visit: |
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| Please Enter the Following Student Information: |
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| * Please enter the student's current type of school of attendance: |
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| * Select the student's grade level. |
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| * Select the student's gender identity. |
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| Enter the student's ethnicity. |
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| Enter the following information for the student.
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| Please answer the following questions related to what makes it hard for the student to regularly attend school. Mark all that apply. Leave blank if not applicable. |
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| Parent/caregiver discretion, including... |
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| Academic issues, including... |
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| Cultural disconnect issues, including... |
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| Relationship issues, including... |
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| Student safety concerns, including... |
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| Lack of coordination with other services and systems, including… |
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| Parent/Caregiver health, including... |
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| School-related discipline issues, including… |
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| Student access to physical, mental or dental health care, including... |
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| Student mental health issues, including... |
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| Student physical health, including... |
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| Student responsibilities outside of school, including... |
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| Transportation challenges, including... |
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| Unfulfilled basic needs, including... |
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