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Intake Assessment
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Expect Respect Support Group Evaluation |
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OMB No. __0920-xxxx_
Exp. Date:
Public
Reporting burden of this collection
of information is estimated at 15 minutes per response, including
the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. 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. Send comments regarding this burden estimate or any
other aspect of this collection of information, including
suggestions for reducing this burden to CDC/ATSDR Reports Clearance
Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn:
PRA (0920-xxxx).
School:_____________________________
Data Collector:___________________________
Student ID: ___________________
Screening Date: ___________________
Student is eligible to participate in ERSG Evaluation because (check all that apply):
_____ Is between age 11 to 17
_____ Reports history of witnessing domestic violence
_____ Reports history of experiencing child abuse (emotional/mental, physical, sexual, neglect)
_____ Is or has been involved in abusive peer and/or dating relationships
_____ Other (e.g. community violence)
Student is not eligible to participate in ERSG Evaluation because (check all that apply):
_____ Student is under age 11 or over age 17
_____ Has never experienced (i.e., been a victim, perpetrator, or witness of) any form of violence
_____ Student requires higher level of care than ERSG can provide (i.e., student is in crisis – acute emotional upset, suicidal or homicidal ideations)
Next steps:
_____ Participation in ERSG
_____ Participation in control group
_____ Referral: ________________________
_____ 1-3 sessions of psychoed
_____ Student received info packet and resources.
Does the student give permission to be contacted for follow-up by phone, by e-mail or by mail?
______ YES (phone #____________________________, e-mail, address )
______ NO
File Type | application/msword |
File Title | Appendix 2a |
Subject | Expect Respect Support Group Evaluation |
Author | imh1 |
Last Modified By | its7 |
File Modified | 2010-06-28 |
File Created | 2010-06-24 |