Form G - DxInt. Im Form G - DxInt. Im Form G - DxInt. Improvement Measure

OMB # 0930- XXXX

Expiration Date: xx/xx/xxxx

SAMHSA FASD Center for Excellence

Form G

Diagnosis and Intervention Programs

End of Intervention Improvement Measure

Parent/Caregiver

This form is used in the SAMHSA FASD Center for Excellence Diagnosis and Intervention Programs to determine overall improvement in the child as a result of receiving services. To protect privacy, name and any other individually identifying information will not be collected. It is important to us to obtain this information to determine if the child is improving as a result of receiving services; however, participation is voluntary.

Child ID: ______________

To be completed by Parent/Caregiver

Date Assessment Completed: _________

Please complete the overall improvement you have observed in the child.

Question: Indicate on a scale of 0-3 the level of improvement you think your child has attained as a result of receiving services for an FASD (Fetal Alcohol Spectrum Disorders).

___ 0 - No improvement

___ 1 - Little improvement

___ 2 - Some or moderate improvement

___ 3 - High level of improvement

Comments: ____________________________________________________________

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-xxxx. Public reporting burden for this collection of information is estimated to average 1 minute per client per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 7-1044, Rockville, Maryland, 20857.

1