Below you will find resources for MIECHV providers, including assessment tools, reporting forms, and fiscal forms.

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Program Plan and Reporting

The following are forms pertaining to program planning and reporting:

Program Monitoring

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 katherine.staten@illinois.gov.

Fiscal

The following are forms applicable to various fiscal issues:

All fiscal documents and correspondence should be sent to Audrey Moy at Audrey.moy@illinois.gov and Lydia McAfee at Lydia.mcafee@illinois.gov.

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Assessments

  • 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 kathy.staten@illinois.gov.
  • 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.

Data Collection 

  • 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.

Professional Development

For forms related to professional development for MIECHV home visitors, Coordinated Intake (CI) staff and supervisors, please click here.

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.