4b2 Ciuf

4.B.2.

Child Information Update Form (CIUF)

NOTE TO OMB REVIEWER:

No burden is attached to this instrument. It is included here for illustrative purposes only.

CHILD INFORMATION UPDATE FORM (CIUF)

CIUFDATE (Today’s date) / /

Month Day Year

CHILDID (National evaluation ID)

TIMEFRAM (Assessment period) 2 = 6 months

3 = 12 months

4 = 18 months

5 = 24 months

A. Sources of information used to complete this form [Select all that apply]

1 = Caregiver (child’s caregiver in a family, household environment)

2 = Staff as Caregiver (staffperson who has acted as the child’s day-to-day caregiver for the majority of the past 6 months)

3 = Youth

4 = Case record review

5 = Other

B. Agency that the child is currently involved with [Select all that apply]

1 = Corrections

2 = Juvenile court

3 = Probation

4 = School

5 = Mental health agency/clinic/provider

6 = Physical health care agency/clinic/provider

7 = Public child welfare

8 = Substance abuse agency/clinic/provider

9 = Family court

10 = Early care: Early Head Start program

11 = Early care: Head Start program

12 = Early care: Early intervention (Part C)

13 = Early care: Preschool special education program (Part B)

14 = Early care: Other early care and education programs/providers (including childcare/providers)

15 = Other—please specify

__________________________

B1. Child welfare involvement

1 = Receiving child abuse and neglect investigation/assessment

2 = Court-ordered out-of-home placement— Foster care

3 = Court-ordered out-of-home placement—Kinship care

4 = Court-ordered out-of-home placement—Residential treatment

5 = Voluntary out-of-home placement— Foster care

6 = Voluntary out-of-home placement— Kinship care

7 = Voluntary out-of-home placement—Residential treatment

8 = Court-ordered in-home services

9 = Voluntary in-home services

SECTION I. Child Demographic Information

[Questions #1–4 are skipped, as they are not applicable.]

5.	What is the ZIP Code of the address where (child’s name) currently lives? _______________

[Question #6 is skipped, as it is not applicable.]

7.	During the past 6 months, was (child’s name) the recipient of . . . ? [Select all that apply] 1 = Medicaid 2 = CHIP 3 = SSI 4 = TANF 5 = CMHS grant program funds 6 = Private insurance 7 = Other—please specify ____________________________________

SECTION II. Child Diagnostic Information: DSM–IV–R and ICD–9

Children may have diagnostic codes for more than one classification system (e.g., DSM–IV–R and DC:0–3R).

8.	Does (child’s name) have a DSM–IV–R or ICD–9 diagnosis? 1 = No [GO TO QUESTION #13] 2 = Yes

[Question #9 is skipped, as it is not applicable.]

In this section, please record the DSM–IV–R or ICD–9 diagnostic codes in the indicated fields.

10.

Date of the most recent multiaxial diagnostic evaluation ________________________________ (mm/dd/yyyy)

11.

Who provided the diagnosis? 1 = Child psychiatrist 2 = General psychiatrist 3 = Child psychologist 4 = General psychologist 5 = Licensed mental health staff (clinical social worker/professional counselor/ therapist) 6 = Primary care physician 7 = Nurse practitioner psychiatric nurse practitioner/physician’s assistant) 8 = Other licensed physical health staff 9 = Unlicensed staff (mental health assessment specialist) 10 = Other—please specify ____________________________________ 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing

[Primary diagnosis should be listed as the first diagnosis on each axis (1a, 2a).]

12.	AXIS I: Clinical Disorders Diagnostic code DSM–IV–R name axis_1a _________.____ _________________________________________ axis_1b _________.____ _________________________________________ axis_1c _________.____ _________________________________________
	AXIS II: Personality Disorders and Mental Retardation Diagnostic code DSM–IV–R name axis_2a _________.____ _________________________________________ axis_2b _________.____ _________________________________________
	AXIS III: General Medical Condition (ICD–9–CM numeric code) [Separate multiple codes with commas] ICD–9–CM numeric code axis 3 ______________________________________________________________________
	AXIS IV: Psychosocial and Environmental Problems [Select all that apply] 1 = Problems with primary support group 2 = Problems related to the social environment 3 = Educational problems 4 = Occupational problems 5 = Housing problems 6 = Economic problems 7 = Problems with access to health care services 8 = Problems related to interaction with the legal system/crime 9 = Other psychosocial and environmental problems 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	AXIS V: Global Assessment of Functioning Scale (GAF) [Enter current GAF score]	_______________

SECTION III. Child Enrollment Information

[Question #13 is skipped, as it is not applicable.]

13a. System of care enrollment status of the child 1 = Child is receiving system of care services [GO TO QUESTION #13c] 2 = Formally completed services/discharged [GO TO QUESTION #13c] 3 = Family no longer receiving services, but not discharged [GO TO QUESTION #13c] 4 = Other—please specify ____________________________________ [GO TO QUESTION #17]

[Question #13b is skipped, as it is not applicable.]

	13c. Date of the child’s most recent assessment for the system of care ________________________________ (mm/dd/yyyy)
	13d. Date of the child’s most recent service planning team meeting in the system of care ________________________________ (mm/dd/yyyy)
	13e. Date of the child’s most recent service received through the system of care ________________________________ (mm/dd/yyyy)

[Questions #13f–16 are skipped, as they are not applicable.]

SECTION IV. Additional Child Diagnostic Information: Revised DC:0–3 (DC:0–3R)

17.

Does (child’s name) have diagnostic information for the Revised DC:0–3 (DC:0–3R)? [Note: The DC:0–3R codes are intended for use with children up to age 4.] [Enter 666 if the child is aged 4 or older.] 1 = No [END OF QUESTIONNAIRE] 2 = Yes 666 = Not applicable [END OF QUESTIONNAIRE] 777 = Refused to answer [END OF QUESTIONNAIRE] 888 = Don’t know [END OF QUESTIONNAIRE] 999 = Missing [END OF QUESTIONNAIRE]

[Question #18 is skipped, as it is not applicable.]

19.	Date of the most recent DC:0–3R diagnostic evaluation ________________________________ (mm/dd/yyyy)
20.	Who provided the diagnosis? 1 = Child psychiatrist 2 = General psychiatrist 3 = Child psychologist 4 = General psychologist 5 = Licensed mental health staff (clinical social worker/professional counselor/ therapist) 6 = Primary care physician 7 = Nurse practitioner psychiatric nurse practitioner/physician’s assistant) 8 = Other licensed physical health staff 9 = Unlicensed staff (mental health assessment specialist) 10 = Other—please specify ____________________________________ 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
21.	AXIS I: Clinical Disorders [Select from the attached list of DC:0–3R Axis I codes]
	21a. First/primary diagnosis ____________________________________________________ [If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g., DSM, ICD9, ICD10]
	21b. Second diagnosis ____________________________________________________ [If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g., DSM, ICD9, ICD10]
	21c. Third diagnosis ____________________________________________________ [If “800 = other disorders” selected, please specify the code with the appropriate prefix, e.g., DSM, ICD9, ICD10]

DC:0–3R Axis I codes:

100 = Posttraumatic Stress Disorder

150 = Deprivation/Maltreatment Disorder

200 = Disorders of Affect

210 = Prolonged Bereavement/Grief Reaction

220 = Anxiety Disorders of Infancy and Early Childhood

221 = Separation Anxiety Disorder

222 = Specific Phobia

223 = Social Anxiety Disorder (Social Phobia)

224 = Generalized Anxiety Disorder

225 = Anxiety Disorder NOS (Not Otherwise Specified)

230 = Depression of Infancy and Early Childhood

231 = Type 1 (type I) Major Depression

232 = Type 2 (type II) Major Depression

240 = Mixed Disorders of Emotional Expressiveness

300 = Adjustment Disorder

400 = Regulation Disorders of Sensory Processing

410 = Hypersensitive

411 = Hypersensitive—Type A: Fearful/Cautious

412 = Hypersensitive—Type B: Negative/Defiant

420 = Hyposensitive/Underresponsive

430 = Sensory Stimulation-Seeking/Impulsive

500 = Sleep Behavior Disorder

510 = Sleep-Onset Disorder (Sleep-Onset Protodyssomnia)

520 = Night-Waking Disorder (Night-Waking Protodyssomnia)

600 = Feeding Behavior Disorder

601 = Feeding Disorder of State Regulation

602 = Feeding Disorder of Caregiver–Infant Reciprocity

603 = Infantile Anorexia

604 = Sensory Food Aversions

605 = Feeding Disorder Associated With Concurrent Medical Condition

606 = Feeding Disorder Associated With Insults to the Gastrointestinal Tract

700 = Disorders of Relating and Communicating

710 = Multi-System Developmental Disorder (MSDD)

800 = Other Disorders (DSM–IV–TR or ICD10)

666 = Not applicable

777 = Refused to answer

888 = Don’t know

999 = Missing

22.	AXIS II: Relationship Classification: Parent–Infant Relationship Global Assessment Scale (PIR–GAS)
	22a. Parent–Infant Relationship Global Assessment Scale (PIR–GAS) Score [Enter PIR–GAS score—valid scores range from 1 to 100] _________________ [IF 1–100, GO TO QUESTION #23] 666 = Not applicable [GO TO QUESTION #22b] 777 = Refused to answer [GO TO QUESTION #22b] 888 = Don’t know [GO TO QUESTION #22b] 999 = Missing [GO TO QUESTION #22b]
	22b. Parent–Infant Relationship Global Assessment Scale (PIR–GAS) Categories [Choose one, only if numeric PIR–GAS score is not entered above] 91–100 = Well adapted 81–90 = Adapted 71–80 = Perturbed 61–70 = Significantly perturbed 51–60 = Distressed 41–50 = Disturbed 31–40 = Disordered 21–30 = Severely disordered 11–20 = Grossly impaired 1–10 = Documented maltreatment 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
23.	AXIS II: Relationship Classification: Relationship Problems Checklist (RPCL) [Choose one for each relationship feature]
	23a. Overinvolved 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	23b. Underinvolved 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	23c. Anxious/tense 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	23d. Angry/hostile 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	23e. Verbally abusive 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	23f. Physically abusive 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	23g. Sexually abusive 1 = No evidence 2 = Some evidence, needs further investigation 3 = Substantive evidence 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
24.	AXIS III: General Medical Condition (ICD–9–CM/ICD–10 numeric code) [Separate multiple codes with commas] ICD–9–CM/ICD–10 numeric code ___________________________________________________________________________
25.	AXIS IV: Psychosocial and Environmental Problems [Select all that apply] 1 = Problems with primary support group 2 = Problems related to the social environment 3 = Educational/childcare problems 4 = Occupational problems 5 = Housing problems 6 = Economic problems 7 = Problems with access to health care services 8 = Problems related to interaction with the legal system/crime 9 = Other psychosocial and environmental problems 10 = Problems related to health of the child 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
26.	AXIS V: Emotional and Social Functioning: Capacities for Emotional and Social Functioning Rating Scale [Choose one functional rating for each emotional/functioning capacity]
	26a. Attention and regulation 1 = Age-appropriate functioning, all conditions and full affect 2 = Age-appropriate functioning, vulnerable to stress or limited range of affect 3 = Functions immaturely (has the capacity but not at age-appropriate level) 4 = Functions inconsistently without special sensorimotor support 5 = Barely evidences the capacity, even with support 6 = Has not achieved this capacity 7 = N/A, child below age level 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	26b. Forming relationships/mutual engagement 1 = Age-appropriate functioning, all conditions and full affect 2 = Age-appropriate functioning, vulnerable to stress or limited range of affect 3 = Functions immaturely (has the capacity but not at age-appropriate level) 4 = Functions inconsistently without special sensorimotor support 5 = Barely evidences the capacity, even with support 6 = Has not achieved this capacity 7 = N/A, child below age level 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	26c. Intentional two-way communication 1 = Age-appropriate functioning, all conditions and full affect 2 = Age-appropriate functioning, vulnerable to stress or limited range of affect 3 = Functions immaturely (has the capacity but not at age-appropriate level) 4 = Functions inconsistently without special sensorimotor support 5 = Barely evidences the capacity, even with support 6 = Has not achieved this capacity 7 = N/A, child below age level 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	26d. Complex gestures and problem-solving 1 = Age-appropriate functioning, all conditions and full affect 2 = Age-appropriate functioning, vulnerable to stress or limited range of affect 3 = Functions immaturely (has the capacity but not at age-appropriate level) 4 = Functions inconsistently without special sensorimotor support 5 = Barely evidences the capacity, even with support 6 = Has not achieved this capacity 7 = N/A, child below age level 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	26e. Use of symbols to express thoughts/feeling 1 = Age-appropriate functioning, all conditions and full affect 2 = Age-appropriate functioning, vulnerable to stress or limited range of affect 3 = Functions immaturely (has the capacity but not at age-appropriate level) 4 = Functions inconsistently without special sensorimotor support 5 = Barely evidences the capacity, even with support 6 = Has not achieved this capacity 7 = N/A, child below age level 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing
	26f. Connecting symbols logically/abstract thinking 1 = Age-appropriate functioning, all conditions and full affect 2 = Age-appropriate functioning, vulnerable to stress or limited range of affect 3 = Functions immaturely (has the capacity but not at age-appropriate level) 4 = Functions inconsistently without special sensorimotor support 5 = Barely evidences the capacity, even with support 6 = Has not achieved this capacity 7 = N/A, child below age level 666 = Not applicable 777 = Refused to answer 888 = Don’t know 999 = Missing