RECORD FORM: Infant/Toddler HOME I. RESPONSITIVITY 24 ...

RECORD FORM: Infant/Toddler HOMEPlace a plus (+) or minus (-) in the box alongside each item depending on whether the behavior is observed during the visit, or ifthe parent reports that the conditions or events are characteristic of the home environment. Enter the subtotals and the total onthe Summary Sheet. Observation (O), Either (E), or Interview (I) is indicated for each item.24. Child has a special place for toys andI. RESPONSITIVITYtreasures. E1. Parent permits child to engage in “messy” play. I 25. Child’s play environment is safe. O2. Parent spontaneously vocalizes to child at leasttwice. OIV. LEARNING MATERIALS3. Parent responds verbally to child’s vocalizations 26. Muscle activity toys or equipment. Eor verbalizations. O4. Parent tells name of object or person during27. Push or pull toy. Evisit. O5. Parent’s speech is distinct, clear, and audible. O 28. Stroller or walker, kiddie car, scooter, ortricycle. E6. Parent initiates verbal interchanges with Visitor. 29. Cuddly toy or role-playing toys. EO7. Parent converses freely and easily. O 30. Learning facilitators—mobile, table andchair, high chair, play pen. E8. Parent spontaneously praises child at least twice. 31. Simple eye-hand coordination toys. EO9. Parent’s voice conveys positive feelings toward 32. Complex eye-hand coordination toys. Echild. O10. Parent caresses or kisses child at least once. O 33. Toys for literature and music. E11. Parent responds positively to praise of child34. Parent provides toys for child to play withoffered by Visitor. Oduring visit. OII. ACCEPTANCEV. INVOLVMENT12. No more than once instance of physical25. Parent talks to child while doing householdpunishment during past week. Iwork. I13. Family has a pet. E 36. Parent consciously encouragesdevelopmental advance. I14. Parent does not shout at child. O 37. Parent invests maturing toys with value viapersonal attention. I15. Parent does not express overt annoyance with or 38. Parent structures child’s play periods. Ihostility to child. O16. Parent neither slaps nor spanks child during39. Parent provides toys that challenge child tovisit. Odevelop new skills. I17. Parent does not scold or criticize child during40. Parent keeps child in visual range, looks atvisit. Ooften. O18. Parent does not interfere with or restrict childmore than three times during visit. OVI. VARIETY19. At least ten books are present and visible. E 41. Father provides some care daily. I42. Parent reads stories to child at least threeIII. ORGANIZATIONtimes weekly. I20. Child care, if used, is provided by one of three 43. Child eats at least one meal a day withregular substitutes. Imother and father. I21. Child is taken to grocery store at least once a44. Family visits relatives or receives visits onceweek. Ia month or so. I22. Child gets out of house at least four times a45. Child has three or more books of his/herweek. Iown. E23. Child is taken regularly to doctor’s office orclinic. ITOTALS I______ II______ III______ IV______ V______ VI______ TOTAL______Caldwell & Bradley Copyright 2003.

Infant/Toddler HOME InventoryData Collection SheetFor Secure Public Health Electronic Records Environment (SPHERE)Family Name/ID _________________________ Date __________Conducted by________________________Child’s name/ID_______________________________Birthdate____________________Age_________________Address__________________________________________________________Phone____________________Comments/Additional Information _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________SCORING SUMMARYSubscaleCutoffScoreActual ScoreCommentsI. RESPONSIVITY 7II. ACCEPTANCE 5III.ORGANIZATION 4IV. LEARNINGMATERIALS5V. INVOLVEMENT 3VI. VARIETY 2TOTAL SCORE 26