Family Interview Form printable pdf download

142. ATTACHMENT

Programs for Migrant Students – Family Interview Form

To be completed by Building Principal or designee: (please print)

________________________

___________

_____________________

Child Name

Birth Date

Grade

School

___________________________________

______________________________

Name of Parent/Guardian

Language(s)

___________________________________

______________________________

Telephone Number or other Contact Information

Today's Date

Needs Assessment

Please Check Response

 Yes

 No

1. Do any of your children have health problems that

interfere with their ability to learn?

Explain:

______________________________

2. In what areas might your child(ren) need additional help in school?

Reading

Math

Language

Other (specify)



 _____________________

Child 1



 _____________________

Child 2



 _____________________

Child 3

 Yes

 No

 Don't know

3. Are your child’s(ren’s) immunizations up to date?

 Yes

 No

 Don't know

4. Do you have immunization records?

5. Have you established a source of primary

 Yes

 No

 Don't know

healthcare?

If not, would you be interested in information on

 Yes

 No

 Don't know

Primary healthcare?

Resources and Referrals

Please Check Response

1. Would you be interested in information on:

 Yes

 No

Public/County Health Dept.

 Yes

 No

Division of Family Services

2. May we share your name and address with

 Yes

 No

these agencies?

3. When is the best time to reach you at home?

 AM

 PM

Days of the week:

 Monday

 Tuesday

 Wednesday

 Thursday

 Friday

___________________________________

______________________________

Name of Person Completing Form

Name of Person Being Interviewed and

His/Her Relationship to Family/Children

Family Interview Form

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