Committed Youth Data Analysis Form

This document must be submitted with the grant application. Applications that are not submitted with data will not be accepted. A separate data analysis form should be submitted for each county in the program service area.

County

Date Completed

Number of Youth in Analysis

Youth in Analysis were committed to DYS between and

Admissions Type

Admissions Type / Number / Percent of Total Reviewed
HIT
Commitment

Risk Assessment Instrument

Age at First Referral / Number / Percent of Total Reviewed / Total Number of Referrals / Number / Percent of Total Reviewed
16 or older / One
14 or 15 / Two or Three
13 or younger / Four or More
Referrals for Violent/Assault Offenses / Number / Percent of Total Reviewed / Prior Out-of-Home Placements / Number / Percent of Total Reviewed
None / None
One or more / One
Two or more
School Discipline/Attendance / Number / Percent of Total Reviewed / Substance Abuse / Number / Percent of Total Reviewed
Enrolled, Attending, No Suspensions; or Grad/GED / No problem or experimentation only
Some truancy; 1-2 Suspensions; Somewhat disruptive / Use sometimes interferes with functioning
Major truant or drop-out; 3+ suspensions; Very disruptive / Use frequently interferes with functioning; Chronic abuse


Risk Assessment Instrument (cont’d)

Peer Relationships / Number / Percent of Total Reviewed / Victim of Abuse or Neglect / Number / Percent of Total Reviewed
Friends provide positive influence / No
Some delinquent friends / Yes
Most delinquent friends
Gang member/associate
Parental Supervision / Total Number Reviewed / Percent of Total Reviewed / Parent/Sibling Criminality / Total Number Reviewed / Percent of Total Reviewed
Parental supervision effective; Youth obeys rules; Minor conflict / No parents/siblings incarcerated or probation in last three years
Parental supervision ineffective; Frequent conflict / Parent/sibling incarcerated or on probation in last three years
Little parental supervision or discipline; Constant conflict

Risk Score Most Serious Adjudication related to this commitment

4

Committed Youth Data Analysis Form

Total Risk Score / Total Number Reviewed / Percent of Total Reviewed
Low (-4 to 0)
Medium (1 to 5)
High (6 to 8)
Very High (9+)
Offense / Total Number Reviewed / Percent of Total Reviewed
Felony Person Offense
Other Person Offense
Weapons Offense
Drug Offense
Property Offense
Public Order Offense
Violation of Probation
CHINS
Other

4

Committed Youth Data Analysis Form


Needs/Strengths Assessment Instrument - Family Needs/Strengths

Care-Giver Substance Abuse / Total Number Reviewed / Percent of Total Reviewed / Family Relationships / Total Number Reviewed / Percent of Total Reviewed
No history of use by caregiver / Supportive family relationships
Use but no dependence / Frequent verbal conflict but stable home
Previous history of abuse only / Routine conflict, unstable home
In recovery, has had relapse / Repeated physical, emotional abuse
Some disruption in functioning / Abusive home environment resulting in injuries
Major disruption in functioning
Living Situation/Finances / Number / Percent of Total Reviewed / Parenting Skills / Number / Percent of Total Reviewed
Suitable home, adequate resources / Strong parenting skills
Receiving income supports, but able to meet needs / Some improvement needed
Has housing but does not meet health/safety needs / Significant shortcomings
Serious living condition problems / Destructive/abusive parenting

Needs/Strengths Assessment Instrument - Youth Needs/Strengths

Adult Relationships / Number / Percent of Total Reviewed / Employment/Vocational Prep. / Number / Percent of Total Reviewed
Good relationship with parents, no strong relationships with other pro-social adults / In school full-time
Good relationship with parents, strong relationships with several other pro-social adults / Not in school, is employed full-time
Poor relationship with parents, strong relationships with several other adults / Not in school, working less than 20 hours per week
Poor relationship with parents, strong relationship with one pro-social adult / Motivated to work, but needs training
No strong relationships with any pro-social adults, home or community / Not in school, not employed, few skills, not motivated

Needs/Strengths Assessment Instrument - Youth Needs/Strengths (cont’d)

Aggressive Assaultive Behavior / Number / Percent of Total Reviewed / Emotional Stability / Number / Percent of Total Reviewed
Resolves conflict without verbal threats or assaultive behavior / Normal adolescent behavior
Occasionally provokes fights, sometimes threatening/verbally abusive / Conduct or substance abuse problems, present behavioral difficulties (not result of emotional instability)
Frequently involved in threatening/assaultive behavior / Mental health issues that do not prohibit adequate functioning, issues are well controlled.
Mental health issues which prohibit or severely limit adequate functioning
History of Abuse as Victim / Total Number Reviewed / Percent of Total Reviewed / Involvement in Activities / Total Number Reviewed / Percent of Total Reviewed
No history of abuse or neglect / In school, involved in structured extracurricular activities
1 or 2 abuse/neglect incidents / In school, involved in unstructured activities
Chronic abuse/neglect / Not in school, working full-time
Any history of sexual abuse / In school, interested in structured/unstructured activities but not involved
In school but not involved and not interested in structured/unstructured activities
Not in school and not involved in any activities or working

4