Injury Plus SEEK Tool – Birth to 12 months

Please enter information below for the child being seen today at a birth to 12 month well-child visit. If the child is being seen for an 18 month to 5 year visit, please click here. If more than one child under 5 is being seen today, please answer for the youngest child. This is voluntary. You don’t have to answer any question you prefer not to.

Being a parent is not always easy.  We want to help families have a safe environment for kids. So, we’re asking everyone these questions. They are about problems that affect many families. If there’s a problem, we’ll try to help.

• Social Needs
• Family Needs
• Car Safety
• Safe Sleep
• Home Safety

Social Needs

1. Would you like help finding a job or employment?

 Yes

 No

2. Would you like help finding daycare for your child?

 Yes

 No

3. Do you have trouble paying utilities or maintaining a safe place to live?

 Yes

 No

4. In the past 12 months, did you worry that your food would run out before you could buy more?

 Yes

 No

5. In the past 12 months, did the food you bought just not last and you didn’t have money to get more?

 Yes

 No

Family Needs

6. Do you often feel your child is difficult to take care of?

 Yes

 No

7. Do you sometimes find you need to slap or hit your child?

 Yes

 No

8. Do you wish you had more help with your child?

 Yes

 No

9. Do you often feel under extreme stress?

 Yes

 No

10. Over the past 2 weeks, have you often felt down, depressed, or hopeless?

 Yes

 No

11. Over the past 2 weeks, have you felt little interest or pleasure in doing things?

 Yes

 No

12. Thinking about the past 3 months, have you and a partner fought a lot?

 Yes

 No

13. Thinking about the past 3 months, has a partner threatened, shoved, hit or kicked you or hurt you physically in any way?

 Yes

 No

14. Does anyone smoke at home?

 Yes

 No

15. Thinking about the past 3 months, have you had 4 or more drinks in one day?

 Yes

 No

16. Thinking about the past 3 months, have you used an illegal drug or a prescription medication for nonmedical reasons?

 Yes

 No

17. Are there any other questions you’d like help with today?

 Yes

 No

18. Do you prefer to complete survey’s such as this on paper or on a computer or tablet?

 Prefer paper

 Prefer computer or tablet

 No preference

Car Safety

19. In what seat and direction does your child usually ride when in a car?

 Front seat – facing forward

 Front seat – facing backward

 Back seat – facing forward

 Back seat – facing backward

20. Has your car seat ever been installed/checked by a car seat expert (such as a nurse, firefighter, law enforcement or car seat technician)?

 Yes

 No

Safe Sleep

21. Do you ever sleep with your child in an adult bed or on a couch at nap or night?

 Yes

 No

22. Do you have a space (eg. crib/pack n play) for your child to sleep in for nap and night?

 Yes

 No

23. Do you always place your child to sleep on their back for nap and night?

 Yes

 No

24. Does your child ever sleep with objects (eg. crib bumpers, pillows, blankets, stuffed animals, toys) in their crib?

 Yes

 No

Home Safety

25. Would you like us to give you the phone number for Poison Control?

 Yes

 No

26. Do you have a smoke detector or carbon monoxide alarm for your home?

 Yes

 No

27. Have you taken a course in child lifesaving techniques, such as CPR or first aid, within the past 3 years?

 Yes

 No

28. Some types of furniture have the potential to tip over when a child pulls on it or attempts to climb it (like dressers, TV’s). Are all such pieces of furniture in your home secured to the wall?

 Yes

 No

29. Are there any situations in which you would consider leaving your child alone in a tub with or without an infant tub seat? (For example, to answer the phone.)

 Yes

 No

30. Do you ever hold your child while drinking hot liquids (e.g., while standing, sitting, or walking)?

 Yes

 No

31. Are all vitamins, medications, or potentially harmful household cleaners in your home either in locked storage OR out of the reach of children?

 Yes

 No

 No I would need a cabinet lock

32. If you have guns in the home, are they all in locked storage AND unloaded?

 Yes

 No

 Does not apply to my house

 I prefer not to answer

33. How likely is your child to get small objects like toy parts, coins, watch batteries, & small pieces of food into their hands? (Consider the possibility of older siblings leaving these lying around or that your child could reach them somewhere.)

 Not at all likely

 Only slightly likely

 Moderately likely

 Very likely

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