Below you will find resources for MIECHV providers, including assessment tools, reporting forms, and fiscal forms.
Program Plan and Reporting
The following are forms pertaining to program planning and reporting:
- MIECHV Program Plan: ALL MIECHV Formula grant programs are required to submit its MIECHV Program Plan annually.
- MIECHV Formula Home Visit Quarterly Report Form: All MIECHV Formula grant programs are required to submit this quarterly report to OECD by the 15th of every month. Reports should be emailed to email@example.com. If you are a competitive grant program (Doula), contact the Ounce for your reporting requirements.
- MIECHV Formula CI Quarterly Report Form: All MIECHV Coordinated Intake agencies are required to submit this quarterly report to OECD by the 15th of every month. Reports should be emailed to firstname.lastname@example.org.
- CI Monthly Referral Tracking Form: All MIECHV Coordinated Intake agencies are required to submit this tracking form to OECD with their quarterly report. The form should be emailed to email@example.com.
- MIECHV Voluntary CI Quarterly Report Form: If your community does not receive specific funding for Coordinated Intake your agency must submit the MIECHV Voluntary CI Report Form to OECD by the 15th of every month. Reports should be emailed to firstname.lastname@example.org.
All of the contracts awarded through MIECHV periodically undergo an On-Site Program Quality Review conducted by DHS staff and Maternal Child Health Nurses. A letter will be sent to providers of both home visiting services and coordinated intake services (only those communities that have a specific CI agency/contract) that confirms the visit. Providers will be informed of the documentation needed to complete the review. Prior to the visit, details of the review will be finalized with the Program Manager/Supervisor. The review will consist of an entrance conference, documentation review, observation, and exit conference. The review will be conducted by DHS staff. The review is conducted with Formula Grant recipients only. Competitive (Doula) grant recipients are monitors by the Ounce. Any questions about program monitoring can be directed to email@example.com.
The following are forms applicable to various fiscal issues:
- Annual Spending Plan Form: Submit this spending plan form when requested for a new grant year.
- DHS Revision of Budget Form: Complete and submit this Revision of Budget Form and a narrative explaining the revision for any budget line change over $500.
- MIECHV Additional Budget Request Form: Complete this Budget Request Form when your agency is requesting funds above and beyond the total amount of your approved budget for the fiscal year.
- 4P’s Plus©
- 4P’s Plus© assessments are offered in English and Spanish.
- Instructions for Sending Completed 4P’s Plus© Forms: OECD asks that all programs in Illinois using the 4P’s Plus© follow these directions to send unidentified completed 4P’s Plus© to the Children’s Research Triangle so they can provide the state with a full report on 4P’s Plus© To view past reports click here.
- For more information about 4P’s Plus©, please click here.
- Coordinated Intake Assessment Tool (CIAT): This is the intake tool that all Illinois MIECHV communities must use when recruiting participants. Non-MIECHV programs are permitted to use it as well. For more information about this tool and its use, please contact Katherine Staten at firstname.lastname@example.org.
- Relationship Assessment Tool: This is the MIECHV required intimate partner violence (IPV) assessment tool, and it is available in English and Spanish. To learn more about screening for IPV, please click here.
- Edinburgh Postnatal Depression Scale (EPDS): This is the MIECHV required depression screening tool, and it is available in English and Spanish. For more information about maternal depression, please click here.
- MIECHV Data Consent: This is the required consent all MIECHV participants must sign to participate in a MIECHV program. It is available in English and Spanish.
- MEICHV Data Collection Manual: This manual provides guidance on home visiting data required pursuant to the federal MIECHV program.
- MIECHV Glossary: This glossary contains information about each of the MIECHV benchmarks and additional resources about Visit Tracker and data entry.
- The following are the various Data Collection Sheets to be used:
- Caregiver Data Collection Sheet: This is the required caregiver data collection sheet for MIECHV. A hard copy of this data collection sheet must be available for all caregivers, and all data from this sheet must be entered by home visiting staff into Visit Tracker.
- Postnatally Enrolled Child Data Collection Sheet: This is the required postnatally enrolled child data collection sheet for MIECHV. A hard copy of this data collection sheet must be available for all children who enroll postnatally and are served by a home visiting model, and all data from this sheet must be entered by home visiting staff into Visit Tracker.
- Prenatally Enrolled Child Data Collection Sheet: This is the required prenatally enrolled child data collection sheet for MIECHV. A hard copy of this data collection sheet must be available for all children who are enrolled prenatally and are served by a home visiting model, and all data from this sheet must be entered into Visit Tracker.
This website is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number HRSA-16-172 Maternal, Infant and Early Childhood Home Visiting Program – Formula. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
It takes a village. Illinois home visiting collaborates with numerous partners in order to support young children and families. These partners include:
Chapin Hall at the University of Chicago • Children’s Home + Aid • Easter Seals • Ever Thrive Illinois • Family Focus • Fussy Baby Network at the Erikson Institute • Heartland Alliance • Illinois Action for Children • Illinois Association for Infant Mental Health • Illinois Chapter of the American Academy of Pediatrics • Illinois Children’s Mental Health Partnership • Illinois Childhood Trauma Coalition • Illinois Coalition Against Domestic Violence • Latino Policy Forum • Metropolitan Family Services • Mothers and Babies Program at Northwestern University • Prevent Child Abuse Illinois • Robert R. McCormick Foundation • Sargent Shriver National Center on Poverty Law • The Irving Harris Foundation • The Ounce of Prevention Fund • Voices for Illinois Children