SELF SURVEY QUESTIONNAIRE

INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
SELF SURVEY QUESTIONNAIRE
( Use in conjunction with Instruction Booklet)
I. PROGRAM AND CHILD IDENTIFYING INFORMATION
(Case #) Project Case Number
(Agency Code) Agency Code
(Program Code) Program Code
(Reviewer) Name of staff completing review
(Reviewer’s Title) Title of staff completing review
(Review Date) Date of Self-Survey Review
(Child’s DOB) Date of Birth for Child
(Child’s Initials) Initials for Child
(County) County of Official Responsibility – See codes in Instruction Booklet
(Placement Date) Date of present placement
(Placement Code) Placement mechanism
1 Voluntary placement by social services district
2 Placement by school district through Committee on Special Education
3 Placement by Family Court with the social services district for child protective reasons
4 Placement by Family Court with the social services district as a result of a PINS adjudication
5 Placement by Family Court with the social services district as a result of a JD adjudication
6 Placement by DFY as a PINS
7 Placement by DFY as a JD
8 Other (e.g., private pay, out-of-state)
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
(Other Placement) Other Placement mechanism
If Choice 8 is selected for Placement mechanism, specify the mechanism.
(IQ Score) IQ Score (Full Scale Only)
(IQ Test Name) Name of IQ Test
(IQ Test Date) Date of IQ Test
(School Placement) Current School Placement Code
Code
The child is presently attending:
1 No school
2 School on the facility grounds
3 Public school off the facility grounds
4 BOCES off the facility grounds
5 Other
(Other School) Other School Placement
If Choice 5 is selected for the Current School Placement Code, specify the other type of
school where the child is attending school.
II. BEHAVIOR PROBLEMS
A. PRIOR TO PLACEMENT BEHAVIOR PROBLEMS: (Questions 11 - 17)
Consider behaviors that have occurred only in the 6 month period prior to placement in this program.
If the child has been transferred to a program within the agency, consider only behaviors that are
documented in the case record during the 6 months before transfer. If the child was not present in the
agency, use only external-from-agency documentation, i.e., local DSS, probation, police records contained
in the case record.
Use the following codes for questions 11 to 16:
1 None
2 One incident in the 6 month period
3 Two incidents in the 6 month period
4 Three incidents in the 6 month period
Q11. Major assaults (a major assault is one in which serious harm resulted or would have been likely to
result had there not been immediate intervention; e.g., murder or attempted murder, rape, an assault with a
dangerous weapon or object, a serious attack on an individual much weaker, or particularly vicious fighting)
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
Q12. Major vandalism or destruction of property (damage of more than $50)
Q13. Major theft (theft of more than $50 value)
Q14. Robbery involving confrontation with the victim
Q15. Major firesetting (firesetting in which damage of $50 or more is likely or in which someone is
physically in danger)
Q16. Repeated use of hard drugs and/or use of alcohol to the degree that it interferes with daily
functioning
Q17 – Use the following codes for question 17.
1 None
2 The child displayed a repetitive and persistent pattern of behavior in which either basic rights of
others or major societal norms were violated
3 Occasional incidents (once a month or more) of significant behavior such as minor firesetting,
public masturbation, torturing animals
4 Frequent incidents (more than three times a month) of significant behavior such as minor
firesetting, public masturbation, torturing animals
If there is more than one problem, select the one which is most severe.
B. CURRENT BEHAVIOR PROBLEMS (Questions 18 - 34)
If there are indications of behavior problems IN THE PAST 90 DAYS, complete this section. If
there are no significant behavior problems, skip this section.
Use the following codes for questions 18 to 32.
1 Not a problem
2 Less than twice a month in the past 90 days
3 Twice a month to once a week in the past 90 days
4 More than once a week in the past 90 days
Q18. Major assaults (a major assault is one in which serious harm resulted or would have been likely to
result had there not been immediate intervention; e.g., murder or attempted murder, rape, an assault with a
dangerous weapon or object, a serious attack on an individual much weaker, or particularly vicious fighting)
Q19. Major vandalism or destruction of property (damage of more than $50)
Q20. Major theft (theft of more than $50 value)
Q21. Robbery involving confrontation with the victim
Q22. Major firesetting (firesetting in which damage of $50 or more is likely or in which someone is
physically in danger)
Q23. Running away overnight or running away when child had to be returned by authorities
Q24. Truancy (deliberately skipping most or all of the school day)
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
Q25. Alcohol consumption or excessive soft drug use (e.g., pot, hashish)
Q26. Hard drug use/excessive alcohol consumption
Q27-1. Verbal abusiveness (hostile swearing or name calling directed toward others)
Q27-2. Describe problem in question 27-1
Q28. Physical fighting or other minor assault
Q29. Minor theft (theft of less than $50 value)
Q30. Minor vandalism (damage of less than $50 value)
Q31. Tantrums or severe anger outbursts
Q32. Threatening others or bullying
Q33. Resistance to authority (excluding truancy)
Use the following codes for question 33:
1 Not a problem
2 Child is occasionally resistive, but generally cooperates and follows most rules
3 Continual poor attitude or resistiveness but usually obeys rules
4 Often disobeys rules
5 Grossly uncooperative, goes out of his/her way to violate rules or to defy authority
Q34-1. Other significant behavior problems
Use the following codes for question 34-1:
1 None
2 Occasional minor incidents (e.g., cutting classes, wandering away, running away for less
than one day where child returns voluntarily, serious lying, provoking others)
3 Frequent minor incidents
4 Occasional moderate incidents (e.g., minor firesetting, public masturbation or genital
display, torturing animals)
5 Frequent moderate incidents
Q34-2. Describe problem in question 34-1
III. MENTAL ILLINESS AND PSYCHIATRIC SYMPTOMS
A. MENTAL ILLNESS AND PSYCHIATRIC SYMPTOMS PRIOR TO PLACEMENT
(Questions 35 - 36)
Q35. Indicate the choice which most accurately describes the youth's psychiatric symptoms IN THE 6
MONTH PERIOD PRIOR TO PLACEMENT in this facility. The choice should be made on the basis of
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
the youth's actual symptoms, NOT on inferences about how he or she might have behaved in a different
setting.
1 None or slight
2 The child was mentally ill but was able to perform adequately in most daily living activities.
Examples of such disorders include hyperactivity, depression, tic disorders, anxiety disorders or bedwetting
3 The child was mentally ill to the extent that the symptoms presented or seriously interfered with
much of normal daily functioning. Examples of such disorders are severe hyperactivity, schizoid disorders,
major eating disorders (e.g., anorexia nervosa, pica), severe anxiety disorders (e.g., agoraphobia) or severe
personality disorders.
4 The child was mentally ill to the extent that there was a complete inability on the part of the child
to function normally. Examples of such disorders include life-threatening suicidal behavior; active
psychosis characterized by bizarre language; gross and sustained impairments in social relations.
5 There are statements in the record that the child displayed psychiatric symptoms at the time of
placement, but there is not enough information to determine the extent of the problem.
Q36. The child has had:
1 No psychiatric hospitalization in the past six months
2 Psychiatric hospitalization in the past six months
3 Residence in a residential treatment facility in the past six months
4 History of both psychiatric hospitalization and placement in RTF
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
B. CURRENT MENTAL ILLNESS AND PSYCHIATRIC SYMPTOMS (Questions 37 -53)
If there are indications of psychiatric symptoms or emotional disturbance IN THE PAST 90 DAYS,
complete this section. If there are no indications, skip this section.
Q37. Suicide threats, gestures or attempts
1 None
2 Occasional serious threats (a threat is when the child says that he/she is going to kill him/herself,
but makes no attempts or gestures)
3 Frequent serious threats (more than three in the past three months)
4 One or two gestures (a gesture is engaging in suicide-like behavior, but which is unlikely to
actually result in the death of the child, e.g., taking 12 aspirin)
5 More than two gestures
6 One or more serious suicide attempts (serious deliberate action intended to cause death, e.g.,
taking a large quantity of prescription drugs, slicing wrist deeply, throwing oneself in front of a car)
Q38. Self-mutilation or self-abuse (e.g., slapping self, scratching self, biting self, head banging)
1 None
2 Occasional minor incidents and does not cause self-harm
3 Repeated minor incidents to the extent that functioning may be limited
4 Occasional serious incidents of self-abuse in which harm is likely and restraint may be required
5 Frequent incidents of serious self-abuse, child may often be in restraint
Q39. Bizarre behavior (e.g., oddities of motor movement such as peculiar hand or finger movements,
toe walking, tics, etc., that are not the result of a physical disability; continuous spinning, rocking,
growling, barking, talking to trees)
1 None
2 Occasional minor incidents, child's behavior is generally not abnormal
3 Frequent minor incidents which would call attention to the child or stigmatize him or her in most
situations
4 Continual grossly abnormal or bizarre behavior to the extent that the child is always calling
attention to him or herself and most normal functioning is impossible
Q40. Bizarre language (e.g., echolalia, perseveration; do not include swearing, baby talk or speech
disorders such as stuttering)
1 Not a problem
2 Occasional peculiarities
3 Major language peculiarities, but child is able to communicate orally to some extent
4 Child is either totally mute or has such serious language peculiarities that most normal
communication is precluded
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
For questions 41 to 48, use the following codes to describe the symptoms in the past 90 days.
1 Problem not present
2 The problem is significant but the child is able to perform adequately most or all activities of daily
living (get up, get dressed, go to school, interact with others, etc.)
3 The problem prevents or seriously interferes with several important activities (school, interactions
with others, doing chores, etc.)
4 The problem is so severe that most normal functioning is impossible (child is unable to dress,
function in school, relate to people, etc.)
Q41. Hyperactivity and/or attention deficits
Q42. Withdrawal, extreme passivity, lack of responsiveness to surroundings
Q43. Psychotic thought disorders (e.g., hearing voices, hallucinations, bizarre delusions such as
delusions of being controlled, delusions of having no insides, or marked loosening of associations or
illogical thinking not attributed to mental retardation)
Q44. Non-psychotic thought disorders (e.g., grandiosity, magical thinking, bizarre fantasies, recurrent
illusions inappropriate for age)
Q45. Overt depression (do not include normal periods of "the blues" or normal grief or sadness
associated with specific events; the depression must be characterized by symptoms such as loss of interest in
usual activities, fatigue, feelings of worthlessness, diminished ability to think or concentrate)
Q46. Lability and emotional instability (sharp or rapid shifts in interpersonal behavior, mood, selfimage,
attitudes that are inappropriate to environmental circumstances)
Q47. Other affective or emotional disorders (e.g., flat or inappropriate affect, extreme anxiety)
Q48-1. Other psychiatric symptoms (e.g., eating disorders, sleep disturbances, phobias)
Q48-2. Describe problem in Q48-1
Q49. Bedwetting (enuresis)
Use the following codes for question 49:
1 Not a problem
2 Occasional problem
3 Frequent problem (more than weekly)
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
Q50-1. Ability to relate to peers
Use the following codes for question 50-1:
1 No significant problem
2 The child displays an interest in making friends, but does not know how and may have only one
other similarly isolated friend; or child is extremely shy or anxious in social situations
3 The child displays no apparent interest in making friends, derives no pleasure from usual peer
interactions, generally avoids social contact and has no close friends
4 The child is completely unresponsive to other human beings and is totally unable to engage in
normal social interactions, such as an autistic child
5 Other serious disorders in peer relations (e.g., seriously victimized or scapegoated by peers)
Q50-2. Describe other serious disorder if 5 is selected in question 50-1
Q51-1. Primary psychiatric diagnosis (Code, if any)
Q51-2. Primary psychiatric diagnosis (Describe question 51-1, if applicable)
Q52-1. Secondary psychiatric diagnosis (Code, if any)
Q52-2. Secondary psychiatric diagnosis (Describe question 52-1, if applicable)
Q53. Is child currently on psychotropic or anticonvulsant medication?
(This information is being used for planning purposes only)
1 Yes
2 No
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
IV. DEVELOPMENTAL DISABILITIES (Questions 54 - 65)
If the child has one or more developmental disabilities, complete this section. If there are no indications
of developmental disabilities, skip this section.
Q54. Mental retardation (there must be a formal diagnosis in the case record)
1 No mental retardation or borderline mental retardation
2 Mild mental retardation
3 Moderate mental retardation
4 Severe mental retardation
5 Profound mental retardation
6 Child has a diagnosis of mental retardation, but the level is not specified
7 There is no formal diagnosis, but there are indications in the record of mental retardation
Q55. Epilepsy/Seizure disorder
1 None
2 Epileptic/seizure disorder but fully controlled (no seizures in 3 months)
3 Occasional petit mal/partial complex (clusters) seizures
4 Frequent petit mal/partial complex (clusters) or occasional grand mal
5 Frequent grand mal seizures or occasional status epilepticus
6 There is no formal diagnosis of epilepsy, but there are indications in the record that the child has
seizures
Q56. Cerebral palsy (e.g., spastic quadriplegia, athetosis, ataxia)
1 None
2 Child is capable of most normal functioning but requires assistance with some activities
3 Child is capable of some self-care skills but requires assistance with many activities
4 Child is not capable of performing any self-care skills except with extreme difficulty
5 There is no formal diagnosis but there is a statement in the record that there are indications of
cerebral palsy
Q57-1. Other neurological impairments (e.g., spina bifida, Tourette's syndrome; exclude epilepsy and
cerebral palsy)
1 None
2 Child has a diagnosis of other neurological impairments
3 There is no formal diagnosis, but there is a statement in the record that there are indications of
neurological impairments
Q57-2. Describe other neurological impairments coded in question 57-1
Q58. Autism
1 Child is not diagnosed as autistic
2 Child has a formal diagnosis of autism
3 Child does not have a formal diagnosis, but there is a statement in the record of autistic-like
features
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
V. SKILLS IN ACTIVITIES OF DAILY LIVING
If one or more items were checked in Section V-DEVELOPMENTAL DISABILITIES
and there are deficits in ADL skills relative to age expectations, complete this section. If there are no
developmental disabilities, skip this section.
Use the following codes for questions 59 to 65.
1 Completely independent (child performs skills adequately alone and would not draw attention to
self in public situations relative to these skills)
2 Needs further training (possesses some skill but would be expected to improve the skill with
further training)
3 Needs assistance (e.g., physical handicap prevents child from performing skill independently;
extremely distractible child knows how to dress self but will not do so without continual verbal prompts)
4 Needs assistance and further training (child has physical and/or emotional disability impairing the
performance of the skill and needs additional training to refine skill)
5 Completely dependent or cannot presently do
6 Not an age appropriate skill (e.g., a two-year old is not expected to go shopping)
Q59. Eating
Q60. Dressing and grooming
Q61. Toileting
Q62. Uses telephone
Q63. Uses stove to prepare meals
Q64. Uses neighborhood stores for shopping
Q65. Uses laundry to wash clothes
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
VI. HEALTH PROBLEMS AND PHYSICAL DISABILITIES (Questions 66 - 72)
If the child has a significant physical disability or chronic health care need, complete this section. If
there are no physical disabilities or chronic health problems, skip this section.
Q66. Vision
1 Full vision (with correction if necessary)
2 Partial vision
3 Legally blind, but has travel vision
4 No functional vision
Q67. Hearing
1 Normal (with correction if necessary)
2 Hearing is impaired
3 No functional hearing
Q68. Mobility
1 No mobility problems, mobility normal for age
2 Child is unsteady or has significant limp or requires braces or support device, but can walk
independently
3 Child is in wheelchair (or equivalent), but can propel wheelchair independently
4 Child is confined to wheelchair and cannot propel chair independently or is bedfast
Q69. Speech
1 Normal for age
2 Has significant speech problem, but can usually make self understood
3 Has a speech problem to the extent that child is often not understood
4 Has a speech problem to the extent that most oral communication is precluded, or else child is
almost or always mute as a result of a physical disability
5 Little or no speech as a result of psychiatric symptoms or mental retardation
Other serious chronic health problems (e.g., heart disease, scoliosis, diabetes)
For questions 70 and 71, use the following codes for severity in the past 90 days.
1 Problem present, but no interference with functioning
2 Mild interference with functioning
3 Moderate interference with functioning
4 Severe interference with functioning
Q70-1. Other serious chronic health problem
Q70-2. Describe problem
Q71-1. Other serious chronic health problem
Q71-2. Describe problem
APPENDIX C3: CLASSIFICATION INSTRUCTIONS AND SURVEY INSTRUMENT
SELF SURVEY QUESTIONNAIRE
April 2000
Program Manual: STANDARDS OF PAYMENT FOR FOSTER CARE OF CHILDREN
Q72. Does the child receive any specialized health care? (Do not include routine custodial care here,
even though it is provided by a nurse. Only include those procedures which must be provided by a trained
health professional. Exclude oral medication. Also, do not include services for conditions which will be
cured within 60 days)
1 No special health services received
2 Must see physician or other health professional for special procedures, but less than once a week
3 Must see physician or other health professional for special procedures at least once a week
4 Requires continual monitoring by professionals for serious life-threatening health condition, or
requires continuous life support equipment
Q73. Additional Comments