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NATIONAL CAC EVALUATION STUDY
EVALUABILITY ASSESSMENT
DATA COLLECTION FORM
I. FILE ID AND CASE STATUS INFORMATION
1. The study organization involved in this case is:
1.____ the CAC agency
2.____ Comparison Site
2. What is the case identification number?
______(NUMBER)
3. What was the date of the initial investigation/assessment of this case by the study organization?
___/___/___ (MM/DD/YR)
98.___ information missing for this case
99.___ information not being collected by agency
II.CHILD AND FAMILY CHARACTERISTICS
4. What is the child’s date of birth?
1.______(MM/DD/YR)
98.___ information missing for this case
99.___ information not being collected
5. What was the child’s age in years at the time of the first occurrence of the alleged abuse?
1.______(AGE IN YRS)
98.___ information missing for this case
99.___ information not being collected
6. What is the child’s sex?
1.____ male
2.____ female
98.___ information missing for this case
99.___ information not being collected
7. What is the child’s race?
1.____ American Indian or Alaska Native
2.____ Asian
3.____ Black or African American
4.____ Native Hawaiian or Other Pacific Islander
5.____ White
98.___ information missing for this case
99.___ information not being collected
8. What is the child’s ethnic identity?
1.____ Hispanic or Latino
2.____ Not Hispanic or Latino
98.___ information missing for this case
99.___ information not being collected
9. What is the child’s family overall annual household income?
1. ____ AFDC/TANF
2. ____ $10,000 or less
3. ____ $10,001-25,000
4. ____ $25,001-50,000
5. ____ 50,0001 or more
98.___ information missing for this case
99.___ information not being collected
10. What is the child’s placement in school?
1.____ not in school yet
2.____ placement is on grade
3.____ placement is below grade
4. ____ special placement, academic
5.____ special placement, behavior
6.____ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
11. What is the educational level achieved by the child’s male adult caregiver?
1.____ elementary school
2.____ some high school
3.____ high school diploma
4.____ GED
5. ____some undergraduate college
6.____ undergraduate college degree
7.____ graduate education
98.___ information missing for this case
99.___ information not being collected
12. What is the child’s adult male caregiver’s job or occupation?
1.______(OCCUPATION); ______(US CENSUS OCCUPATION CODE)
98.___ information missing for this case
99.___ information not being collected
13. What is the educational level achieved by the child’s adult female caregiver?
1.____ elementary school
2.____ some high school
3.____ high school diploma
4.____ GED
5. ____some undergraduate college
6.____ undergraduate college degree
7.____ graduate education
98.___ information missing for this case
99.___ information not being collected
14. What is the child’s adult female caregiver’s job or occupation?
1.______(OCCUPATION); ______(US CENSUS OCCUPATION CODE)
98.___ information missing for this case
99.___ information not being collected
15. Does the child have a disability?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
16. What disability does the child have? ( CHECK ALL THAT APPLY):
1. ____ cognitive/intellectual impairment(s)
2. ____ learning disability
3. ____ developmental
4. ____ ADD, ADHD
5. ____ emotional
6. ____ orthopedic
7. ____ speech
8. ____auditory
9. ____ visual
10.___ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
17. Is English the child’s primary language?
1.____ yes
2.____ no (SPECIFY PRIMARY LANGUAGE:______)
98.___ information missing for this case
99.___ information not being collected
18. What is the child’s current living situation?
1.____ in parents’ or primary caregiver’s home
2____ in foster/adoptive home
3.____ residing with other relatives
4.____ in residential/institutional treatment
5.____ in group home
98.___ information missing for this case
99.___ information not being collected
19. What was the child’s living situation at the time of the alleged abuse?
1.____ in parents’ or primary caregiver’s home
2.____ in foster/adoptive home
3.____ residing with other relatives
4.____ in residential/institutional treatment
5.____ in group home
98.___ information missing for this case
99.___ information not being collected
20. What was the child’s living situation at the conclusion of the investigation?
1.____ did not relocate (GO TO SECTION III)
2.____ was relocated to known relative
3.____ was relocated to unknown relative
4.____ was placed in foster care
5.____ was placed in residential/institutional care
6.____ in group home
7.____ other (SPECIFY______)
98.___ information missing for this case
99.___ information not being collected
21. If the child was relocated, what was the mandating mechanism?
1.____ voluntary
2.____ CPS, ex parte
3.____ Law Enforcement
4.____ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
III. ALLEGED ABUSE CHARACTERISTICS
22. What type of abuse was the child alleged to have been exposed to? (CHECK ALL THAT APPLY):
1.____ neglect
2.____ physical abuse
3.____ emotional abuse
4.____ sexual abuse
5.____ threat of harm
6.____ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
23. After investigation, what type of abuse was the child believed to have been exposed to? (CHECK ALL THAT APPLY):
1.____ none (GO TO SECTION VI)
2.____ physical neglect
3.____ physical abuse
4.____ emotional abuse
5.____ sexual abuse
6.____ threat of harm
7.____ medical neglect
8.____ educational neglect
9.____ other (SPECIFY:______)
98.___ information missing for this case ( GO TO SECTION IV)
99.___ information not being collected ( “ “ “ IV)
24. Whatever the type of abuse exposed to, was the child in any way physically hurt or injured while being abused?
1.____ no
2.____ yes, mildly so
3.____ yes, moderately so
4.____ yes, severely so
98.___ information missing for this case
99.___ information not being collected
25. Was physical force used in making the child submit to the abuse?
1.____ no
2.____ yes, mildly so
3.____ yes, moderately so
4.____ yes, severely so
98.___ information missing for this case
99.___ information not being collected
26. Was any other form of coercion used to make the child submit to the abuse?
1.____ yes
2.____ no (GO TO QUESTION 28)
98.___ information missing for this case ( GO TO QUESTION 28)
99.___ information not being collected ( GO TO QUESTION 28)
27. What form of coercion was actually used? (CHECK ALL THAT APPLY):
1.____ persuasion ( e.g., seduction, promise of gifts, backrubs)
2.____ verbal threats (e.g., withholding gifts, privileges)
3.____ threatened use of physical, bodily force
4.____ threatened use of fire arm or other weapon
5.____ actual brandishing of a weapon (firearm, knife, etc.)
6.____ other threatening behavior(s) (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
28. Were any other manipulative or exploitative behaviors used to make the child submit?
1.____ yes
2.____ no (GO TO QUESTION 30)
98.___ information missing for this case ( “ “ “ 30)
99.___ information not being collected ( “ “ “ 30)
29. If so, what kind of behaviors were these?
1.____ justification of the abusive act ( e.g., expression of love, trust, etc.)
2.____ injunction against telling others ( e.g., threat, secrecy, etc.)
3.____ grooming
4.____ other manipulative behaviors (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
30. What was the duration of the abuse the child was exposed to?
1.____ one single incident
2.____ one week or less
3.____ more than one week, but not exceeding a month
4.____ multiple months (INDICATE NUMBER OF MONTHS:______)
5.____ one full year
6.____ multiple years (INDICATE NUMBER OF YEARS:______)
7.____ unable to determine
98.___ information missing for this case
99.___ information not being collected
31. How often was the child abused in the current episode under investigation?
_____ (NUMBER OF INCIDENTS OR EPISODES)
2.____ unable to determine
98.___ information missing for this case
99.___ information not being collected
32. What was the non-offending caregiver’s knowledge of the abuse when it occurred?
1.____ had no knowledge of the incident(s) while it ( they) occurred (GO TO QUESTION 34)
2.____ had knowledge of incident
3.____ was suspicious, but not certain
98.___ information missing for this case (GO TO QUESTION 34)
99.___ information not being collected ( “ “ “ 34)
33. What action(s) did this non-offending caregiver take? (CHECK ALL THAT APPLY):
1.____none
2.____contacted law enforcement
3.____ contacted CPS
4.____ contacted LCC ( =CAC agency)
5.____ contacted medical authority
6.____ contacted other(s) (SPECIFY:______)
7.____ relocated child
8.____ relocated with child
9.____ restricted contact child – alleged offender
10.____ removed alleged offender
11.___ took other protective action(s) (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
34. If the child was sexually abused, what kind of sexual behavior(s) was the child exposed to? (CHECK ALL THAT APPLY):
1. ____ sexually suggestive talk, hugs, kissing
2. ____ visual exposing of genitals (abuser or child),
3.____ pornography ( magazines, video, internet, nude picture taking etc. )
4. ____ fondling over child’s clothes
5. ____ fondling under child’s clothes
6. ____ simulated intercourse over clothes
7. ____ child masturbating abuser or involved in abuser’s masturbation
8. ____ simulated intercourse under clothes (penis between child’s legs, no penetration)
9. ____ oral contact (abuser to child’s genitals)
10. ____ oral contact (child to abuser’s genitals)
11..___ digital or object penetration
12. ___ vaginal or anal intercourse(including unsuccessful attempts)
13.___ ejaculation
14. ___ exposition (prostitution)
15. ___ ritual and satanic abuse or sexualized torture
16. ___ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
35. If the child was physically abused, what kind of physically abusive behaviors was the child exposed to? (CHECK ALL THAT APPLY):
1. ____ pushing or shaking
2. ____ excessive disciplinary spanking (limited to buttocks, no injury or bruising)
3. ____ pinching, biting, etc., causing limited surface injury
4. ____ hitting and other minor assaults e.g., hit, punched, kicked, or hit with object
5. ____ using an amount of force that could reasonably be expected to cause serious injury
(e.g., minor bruises in a limited area, a small scratch, etc)
6.____ inflicting burns to a limited extent including minor impulsive burns
(e.g. a single impulsive cigarette burn)
7. ____ threatening with a weapon (e.g. gun or knife)
8. ____ battery, beatings, and other major assaults – hit, punched, kicked, or hit with an object
using a degree of force that could reasonably be expected to cause serious injury
(e.g., severe or numerous bruises, swelling, bleeding, lost teeth, scars, broken bones)
9. ____ attack with weapon (e.g. gun or knife) causing injury
10. ___ being burned extensively (e.g. more than a single burn or any burn with more than a
small surface area)
11.___ kept in restraints, locked up, held in seclusion, other mobility constraints
12.___ sadistic injury or torture
13.___ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
IV. ALLEGED OFFENDER CHARACTERISTICS
36. In this particular case of abuse, has an alleged offender been identified?
1.____ yes
2.____ no (GO TO SECTION V)
98.___ information missing for this case ( “ “ “ V)
99.___ information not being collected ( “ “ “ V)
37. If individuals made the identification of the alleged offender, who were they? (CHECK ALL THAT APPLY):
1.____ the child
2.____ parent(s), step-parent(s), other adult caregiver(s)
3.____ other family members
4.____ extra-familial adult observer, witness, child confidant
5.____ extra-familial child/adolescent observer, witness, child confidant
6.____ other individual(s) (SPECIFY:______)
7.____ other evidence (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
38. If the investigation led to the identification of an alleged offender, which were the major sources of identification?(CHECK ALL THAT APPLY):
1.____ law enforcement investigation
2.____ CPS investigation
3.____ medical evidence
4.____ forensic interview ( CHECK AGENCY(-IES):____LE;____CAC;____CPS;____Other )
5.____ other evidence( SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
39. What was the relationship of the alleged offender to the child exposed to the abuse?
1. ____ biological parent
2. ____ step parent
3. ____ foster parent
4. ____ other relative primary caregiver
5. ____ other relative non-caregiver
6. ____ mother’s paramour
7. ____ father’s paramour
8. ____ sibling, stepsibling
9.____ non-relative caregiver (e.g., daycare staff, teacher, etc.)
10.___ non-relative adult in position of authority to the child
11.___ adult known to the child
12.___ adult unknown to the child
13.___ another child (e.g., neighborhood or school friend, playmate)
14.___ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
40. What is the alleged offender’s sex?
1.____ male
2.____ female
98.___ information missing for this case
99.___ information not being collected
41. What is the alleged offender’s race?
1.____ American Indian or Alaska Native
2.____ Asian
3.____ Black or African American
4.____ Native Hawaiian or Other Pacific Islander
5. ___ White
98.___ information missing for this case
99.___ information not being collected)
42. What is the alleged offender’s ethnic identity?
1.____ Hispanic or Latino
2.____ Not Hispanic or Latino
98.___ information missing for this case
99.___ information not being collected
43. What is the alleged offender’s age in years?
1._____(AGE IN YEARS)
98.___ information missing for this case
99.___ information not being collected
44. If alleged offender’s age is unknown, was he/she ?
1.____ a child
2.____ an adolescent
3.____ an adult
98.___ information missing for this case
99.___ information not being collected
45. Was the alleged offender living with the child at the time of the abuse?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
46. Was the alleged offender reported to be under the influence of alcohol or drugs at the time of the alleged abuse?
1.____ no
2.____ yes, alcohol
3.____ yes, other drugs (SPECIFY:______)
4.____ yes, alcohol and other drugs
98.___ information missing for this case
99.___ information not being collected
47. Was the alleged offender reported to have given alcohol or drugs to the child as part of the abusive act?
1.____ no
2.____ yes, alcohol
3.____ yes, other drugs (SPECIFY:______)
4.____ yes, alcohol and other drugs
98.___ information missing for this case
99.___ information not being collected
48. At the time of the very first investigative interview, had an alleged offender been identified?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
49. If yes, had the alleged offender been arrested or otherwise detained?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
50. At the time of the very first investigative interview, had any court issued a restraining order to protect the child from the alleged offender?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
51. What was the alleged offender’s initial response to the allegation of abuse?
1.____ denies all wrongdoing
2.____ neither denies nor admits
3.____ admits abusive act, but takes no responsibility
4.____ admits and takes full responsibility for the abusive act
98.___ information missing for this case
99.___ information not being collected
52. What was the alleged offender’s final response to the allegationof abuse?
1.____ denies all wrongdoing
2.____ neither denies nor admits
3.____ admits abusive act, but takes no responsibility
4.____ admits and takes full responsibility for the abusive act
98.___ information missing for this case
99.___ information not being collected
53. Was there more than one alleged offender involved in the abuse?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
54. If more than one alleged offender was reported, how many others were identified?
1. ______(NUMBER OF OTHER PERPETRATORS)
98.___ information missing for this case
99.___ information not being collected
V. DISCLOSURE AND REPORTING
55. What was the first indicator that the child might have been abused? (CHECK ONE):
1.____ child disclosure
2.____ child behavior
3.____ psychopathological symptoms ( e.g., anxiety, depression)
4.____ overt physical signs (e.g., bruises)
5.____ medical evidence
6.____ witness
7.____ contact with suspected or known offender
8.____ other (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
56. Did the child involved in the abuse, make a disclosure of that experience?
1.____ yes
2.____ no (GO TO QUESTION 61)
98.___ information missing for this case ( “ “ “ 61)
99.___ information not being collected ( “ “ “ 61)
57. Who was the first person the abused child spoke to about the incident?
1. ____ biological mother
2. ____ biological father
3. ____ stepparent
4. ____ sibling/step-sibling
5. ____ foster parent
6. ____ grandparent
7. ____ other relative
8. ____ friend
9. ____ teacher
10. ___ social worker
11. ___ mental health provider
12. ___ health care provider
13. ___ rape crisis center/victim services
14. ___ law enforcement professional
15. ___ legal representative
16. ___ other adult (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
58. Did the child ever recant the initial disclosure of the abuse experienced?
1.____ yes
2.____ no
98.___ information missing for this case
99.___ information not being collected
59. How much time elapsed between the abusive incident experienced and the child’s disclosure or reportof that incident?
1.____ hours (INDICATE NUMBER OF HOURS:______)
2.____ days (INDICATE NUMBER OF DAYS:______)
3.____ months (INDICATE NUMBER OF MONTHS:______)
98.___ information missing for this case
99.___ information not being collected
60. Who was (were) the primary caregiver(s) of the abused child at the time the abuse took place?
1. ___ biological parent
2. ____ biological parents
3. ____ step parent(s)
4 .____ foster parent(s)
5. ____ other adult relative(s)
6. ____ non-related adult(s)
7.____ residential/institutional care
8. ____ no one
98.___ information missing for this case
99.___ information not being collected
61. In the case of there being one primary caregiver only, what is the caregiver’s sex?
1.____ male
2.____ female
98.___ information missing for this case
99.___ information not being collected
62. What was the marital status of the child’s primary caregiver(s) at the time the abuse took place?
1 ____ married, two parent household (including step/foster parents)
2.____ divorced or separated, single parent household
3.____ widowed, single parent household
4.____ never married, single parent household
5.____ single parent and paramour
6.____ foster or adoptive parent(s)
98.___ information missing for this case
99.___ information not being collected
63. Was the primary caregiver supportive of child following the disclosure or discoveryof the abuse experienced?
1. ____ yes
2. ____ ambivalent
3. ____ no
4. ____ the child did not disclose
98.___ information missing for this case
99.___ information not being collected
64. Was the primary caregiver supportive of the child when informed about the outcome of the forensic interview with the child?
1. ____ yes
2. ____ ambivalent
3. ____ no
4. ____ the child was not interviewed
98.___ information missing for this case
99.___ information not being collected
65. Was the primary caregiver supportive of the child during the course of the legal proceedings about the abuse?
1. ____ yes
2. ____ ambivalent
3. ____ no
4. ____ there were no legal proceedings
98.___ information missing for this case
99.___ information not being collected
VI. AGENCY INVESTIGATION AND MEDICAL EXAMINATION
A. General
66. Which agencies were involved in any investigation or assessment of this particular case? (CHECK ALL THAT APPLY):
1_____ CPS
2.____ law enforcement
3.___ _ Office Prosecutor
4.____ CAC agency
5.____ medical examiner(s) (hospital, clinic, individual physician)
6.____ mental health agency
7.____ social service agency ( non-governmental)
8.____ school
9.____ GAL, CASA
10.___ victim advocacy
11.___ other service entity (SPECIFY:______)
98.___ information missing for this case
99.___ information not being collected
67. If a single-agency case,which agency (among the following three) assumed responsibility for it?
1.____ Law Enforcement (=LE)