Agreement with Maria Castillo PROFESSIONAL SERVICES AGREEMENT
BETWEEN THE CITY OF MIAMI BEACH
AND
MARIA CASTILLO
FOR YOUTH SERVICES, PURSUANT TO
THE CITY'S PARENT-CHILD HOME PROGRAM
This Professional Services Agreement ("Agreement") is entered into this 1St day of August,
2014, between the CITY OF MIAMI BEACH, FLORIDA, a municipal corporation organized and
existing under the laws of the State of Florida, having its principal offices at 1700 Convention
Center Drive, Miami Beach, Florida, 33139 (City), and MARIA CASTILLO, whose address is
225 NE 160 St., North Miami, Florida, 33162 (Consultant).
SECTION 1
DEFINITIONS
Agreement: This Agreement between the City and Consultant, including any exhibits
and amendments thereto.
City Manager: The chief administrative officer of the City.
Consultant: For the purposes of this Agreement, Consultant shall be deemed to be an
independent contractor, and not an agent or employee of the City.
Services: All services, work and actions by the Consultant performed or undertaken
pursuant to the Agreement.
Fee: Amount paid to the Consultant as compensation for Services.
Risk Manager: The Risk Manager of the City, with offices at 1700 Convention Center
Drive, Third Floor, Miami Beach, Florida 33139: telephone number (305)
673-7000, Ext. 6435: and fax number(305) 673-7023.
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 1 of 19
SECTION 2
SCOPE OF SERVICES (SERVICES)
2.1 In consideration of the Fee to be paid to Consultant by the City, Consultant shall provide
home-visiting services for youth and their families in accordance with The Children's Trust
Miami Beach Early Childhood Development Grant, dated August 1, 2014. The scope of work to
be performed by Consultant is further detailed in Exhibit "A", entitled "Scope of Services." The
Consultant shall report to the Program Coordinator or designee of the City of Miami Beach,
Office of Housing & Community Services.
2.2 Consultant's Services, and any deliverables incident thereto, shall be completed in
accordance with the timeline and/or schedule in Exhibit "A" hereto.
SECTION 3
TERM
The term of this Agreement shall commence upon execution of this Agreement by all parties
hereto, and shall terminate on July 31, 2014.
Notwithstanding the Term provided herein, Consultant shall adhere to any specific timelines,
schedules, dates, and/or performance milestones for completion and delivery of the Services,
as same is/are set forth in the timeline and/or schedule referenced in Exhibit "A" hereto.
SECTION 4
FEE
4.1 In consideration of the Services to be provided, Consultant shall be compensated for the
Services, as set forth in Section 2 and Exhibit "A", as follows: (a) Provision of home visits with
program-required supervision and training and other program related tasks, at Thirty One
Dollars and Fifty Cents ($31.50) per hour, for a maximum not to exceed Twenty-Nine Thousand
One Hundred and Six Dollars ($29,106).
Consultant's compensation shall be further subject to and conditioned upon all or any portion of
the Services to be provided herein being allowable and within the Scope of Services delineated
in Exhibit "A".
4.2 INVOICING
Upon receipt of an acceptable and approved invoice, payment(s) shall be made within thirty (30)
days for that portion (or those portions) of the Services satisfactorily rendered (and referenced
in the particular invoice).
Invoices shall include a detailed description of the Services (or portions thereof) provided, and
shall be submitted to the City at the following address:
City of Miami Beach
Office of Housing & Community Services
Attn: Maria L. Ruiz
1700 Convention Center Drive
Miami Beach, Florida 33139
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 2 of 19
SECTION 5
TERMINATION
5.1 TERMINATION FOR CAUSE
If the Consultant shall fail to fulfill in a timely manner, or otherwise violates, any of the
covenants, agreements, or stipulations material to this Agreement, the City, through its
City Manager, shall thereupon have the right to terminate this Agreement for cause.
Prior to exercising its option to terminate for cause, the City shall notify the Consultant of
its violation of the particular term(s) of this Agreement, and shall grant Consultant ten
(10) days to cure such default. If such default remains uncured after ten (10) days, the
City may terminate this Agreement without further notice to Consultant. Upon
termination, the City shall be fully discharged from any and all liabilities, duties, and
terms arising out of, or by virtue of, this Agreement.
Notwithstanding the above, the Consultant shall not be relieved of liability to the City for
damages sustained by the City by any breach of the Agreement by the Consultant. The
City, at its sole option and discretion, shall be entitled to bring any and all legal/equitable
actions that it deems to be in its best interest in order to enforce the City's right and
remedies against Consultant. The City shall be entitled to recover all costs of such
actions, including reasonable attorneys' fees.
5.2 TERMINATION FOR CONVENIENCE OF THE CITY
THE CITY MAY ALSO, THROUGH ITS CITY MANAGER, AND FOR ITS
CONVENIENCE AND WITHOUT CAUSE, TERMINATE THE AGREEMENT AT ANY
TIME DURING THE TERM BY GIVING WRITTEN NOTICE TO CONSULTANT OF
SUCH TERMINATION; WHICH SHALL BECOME EFFECTIVE WITHIN THIRTY (30)
DAYS FOLLOWING RECEIPT BY THE CONSULTANT OF SUCH NOTICE. IF THE
AGREEMENT IS TERMINATED FOR CONVENIENCE BY THE CITY, CONSULTANT
SHALL BE PAID FOR ANY SERVICES SATISFACTORILY PERFORMED UP TO THE
DATE OF TERMINATION; FOLLOWING WHICH THE CITY SHALL BE DISCHARGED
FROM ANY AND ALL LIABILITIES, DUTIES, AND TERMS ARISING OUT OF, OR BY
VIRTUE OF, THIS AGREEMENT.
5.3 TERMINATION FOR INSOLVENCY
The City also reserves the right to terminate the Agreement in the event the Consultant
is placed either in voluntary or involuntary bankruptcy or makes an assignment for the
benefit of creditors. In such event, the right and obligations for the parties shall be the
same as provided for in Section 5.2.
SECTION 6
INDEMNIFICATION AND INSURANCE REQUIREMENTS
6.1 INDEMNIFICATION
Consultant agrees to indemnify and hold harmless the City of Miami Beach and its officers,
employees, agents, and contractors, from and against any and all actions (whether at law or in
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 3 of 19
equity), claims, liabilities, losses, and expenses, including, but not limited to, attorneys' fees and
costs, for personal, economic or bodily injury, wrongful death, loss of or damage to property,
which may arise or be alleged to have arisen from the negligent acts, errors, omissions or other
wrongful conduct of the Consultant, its officers, employees, agents, contractors, or any other
person or entity acting under Consultant's control or supervision, in connection with, related to,
or as a result of the Consultant's performance of the Services pursuant to this Agreement. To
that extent, the Consultant shall pay all such claims and losses and shall pay all such costs and
judgments which may issue from any lawsuit arising from such claims and losses, and shall pay
all costs and attorneys' fees expended by the City in the defense of such claims and losses,
including appeals.
The parties agree that one percent (1%) of the total compensation to Consultant for
performance of the Services under this Agreement is the specific consideration from the City to
the Consultant for the Consultant's indemnity agreement. The provisions of this Section 6.1 and
of this indemnification shall survive termination or expiration of this Agreement.
6.2 INSURANCE REQUIREMENTS
The Consultant shall maintain and carry in full force during the Term, the following insurance:
1. Consultant General Liability, in the amount of$1,000,000;
2. Consultant Professional Liability, in the amount of$200,000; and
3. Workers Compensation & Employers Liability, as required pursuant to Florida Statutes.
The insurance must be furnished by insurance companies authorized to do business in the
State of Florida. All insurance policies must be issued by companies rated no less than "B+" as
to management and not less than "Class VI" as to strength by the latest edition of Best's
Insurance Guide, published by A.M. Best Company, Oldwick, New Jersey, or its equivalent.
All of Consultant's certificates shall contain endorsements providing that written notice shall be
given to the City at least thirty (30) days prior to termination, cancellation or reduction in
coverage in the policy.
Original certificates of insurance must be submitted to the City's Risk Manager for approval
(prior to any work and/or services commencing) and will be kept on file in the Office of the Risk
Manager. The City shall have the right to obtain from the Consultant specimen copies of the
insurance policies in the event that submitted certificates of insurance are inadequate to
ascertain compliance with required coverage.
The Consultant is also solely responsible for obtaining and submitting all insurance certificates
for any sub-consultants.
Compliance with the foregoing requirements shall not relieve the Consultant of the liabilities and
obligations under this Section or under any other portion of this Agreement.
The Consultant shall not commence any work and or services pursuant to this Agreement until
all insurance required under this Section has been obtained and such insurance has been
approved by the City's Risk Manager.
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 4 of 19
i
i
I
SECTION 7
LITIGATION JURISDICTION/VENUE/JURY TRIAL WAIVER
This Agreement shall be construed in accordance with the laws of the State of Florida. This
Agreement shall be enforceable in Miami-Dade County, Florida, and if legal action is necessary
by either party with respect to the enforcement of any or all of the terms or conditions herein,
exclusive venue for the enforcement of same shall lie in Miami-Dade County, Florida. By
entering into this Agreement, Consultant and the City expressly waive any rights either party
may have to a trial by jury of any civil litigation related to or arising out of this Agreement.
SECTION 8
LIMITATION OF CITY'S LIABILITY
The City desires to enter into this Agreement only if in so doing the City can place a limit on the
City's liability for any cause of action, for money damages due to an alleged breach by the City
of this Agreement, so that its liability for any such breach never exceeds the sum of $10,000.
Consultant hereby expresses its willingness to enter into this Agreement with Consultant's
recovery from the City for any damage action for breach of contract to be limited to a maximum
amount of$10,000.
Accordingly, and notwithstanding any other term or condition of this Agreement, Consultant
hereby agrees that the City shall not be liable to the Consultant for damages in an amount in
excess of $10,000 for any action or claim for breach of contract arising out of the performance
or non-performance of any obligations imposed upon the City by this Agreement.
Nothing contained in this section or elsewhere in this Agreement is in any way intended to be
a waiver of the limitation placed upon the City's liability, as set forth in Section 768.28, Florida
Statutes.
SECTION 9
[INTENTIONALLY DELETED]
SECTION 10
GENERAL PROVISIONS
10.1 AUDIT AND INSPECTIONS
Upon reasonable verbal or written notice to Consultant, and at any time during normal
business hours (i.e. 9AM — 5PM, Monday through Fridays, excluding nationally recognized
holidays), and as often as the City Manger may, in his/her reasonable discretion and
judgment, deem necessary, there shall be made available to the City Manager, and/or such
representatives as the City Manager may deem to act on the City's behalf, to audit, examine,
and/ or inspect, any and all other documents and/or records relating to all matters covered by
this Agreement. Consultant shall maintain any and all such records at its place of business at
the address set forth in the "Notices" section of this Agreement.
10.2 [INTENTIONALLY DELETETD]
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 5 of 19
10.3 ASSIGNMENT, TRANSFER OR SUBCONSULTING
Consultant shall not subcontract, assign, or transfer all or any portion of any work and/or
service under this Agreement without the prior written consent of the City Manager, which
consent, if given at all, shall be in the Manager's sole judgment and discretion. Neither this
Agreement, nor any term or provision hereof, or right hereunder, shall be assignable unless as
approved pursuant to this Section, and any attempt to make such assignment (unless
approved) shall be void.
10.4 PUBLIC ENTITY CRIMES
Prior to commencement of the Services, the Consultant shall file a State of Florida Form PUR
7068, Sworn Statement under Section 287.133(3)(a) Florida Statute on Public Entity Crimes
with the City's Procurement Division.
10.5 EQUAL EMPLOYMENT OPPORTUNITY
In connection with the performance of the Services, the Consultant shall not discriminate
against any employee or applicant for employment because of race, color, national origin,
religion, sex, gender identity, sexual orientation, disability, marital and familial status, or age.
10.6 CONFLICT OF INTEREST
The Consultant herein agrees to adhere to and be governed by all applicable Miami-Dade
County Conflict of Interest Ordinances and Ethics provisions, as set forth in the Miami-Dade
County Code, and as may be amended from time to time; and by the City of Miami Beach
Charter and Code (as some may be amended from time to time); both of which are
incorporated by reference herein as if fully set forth herein.
The Consultant covenants that it presently has no interest and shall not acquire any interest,
direct or indirectly, which could conflict in any manner or degree with the performance of the
Services. The Consultant further covenants that in the performance of this Agreement, no
person having any such interest shall knowingly be employed by the Consultant. No member
of or delegate to the Congress of the United States shall be admitted to any share or part of
this Agreement or to any benefits arising there from.
SECTION 11
NOTICES
All notices and communications in writing required or permitted hereunder, shall be delivered
personally to the representatives of the Consultant and the City listed below or may be mailed
by U.S. Certified Mail, return receipt requested, postage prepaid, or by a nationally recognized
overnight delivery service.
Until changed by notice in writing, all such notices and communications shall be addressed as
follows:
TO CONSULTANT: Maria Castillo
225 NE 160 St.
North Miami, FL 33162
(786) 975-7730
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 6 of 19
i
r
TO CITY:
Maria L. Ruiz, Director
City of Miami Beach
Office of Housing & Community Services
1700 Convention Center Drive
Miami Beach, Florida 33139
(305) 673-7491
Notice may also be provided to any other address designated by the party to receive notice if such
alternate address is provided via U.S. certified mail, return receipt requested, hand delivered, or by
overnight delivery. In the event an alternate notice address is properly provided, notice shall be
sent to such alternate address in addition to any other address which notice would otherwise be
sent, unless other delivery instruction as specifically provided for by the party entitled to notice.
Notice shall be deemed given on the day on which personally served, or the day of receipt by
either U.S. certified mail or overnight delivery.
SECTION 12
MISCELLANEOUS PROVISIONS
12.1 CHANGES AND ADDITIONS
This Agreement cannot be modified or amended without the express written consent of the
parties. No modification, amendment, or alteration of the terms or conditions contained herein
shall be effective unless contained in a written document executed with the same formality and
of equal dignity herewith.
12.2 SEVERABILITY
If any term or provision of this Agreement is held invalid or unenforceable, the remainder of this
Agreement shall not be affected and every other term and provision of this Agreement shall be
valid and be enforced to the fullest extent permitted by law.
12.3 ENTIRETY OF AGREEMENT
The City and Consultant agree that this is the entire Agreement between the parties. This
Agreement supersedes all prior negotiations, correspondence, conversations, agreements or
understandings applicable to the matters contained herein, and there are no commitments,
agreements or understandings concerning the subject matter of this Agreement that are not
contained in this document. Title and paragraph headings are for convenient reference and are
not intended to confer any rights or obligations upon the parties to this Agreement.
12.4 CONSULTANT'S COMPLIANCE WITH FLORIDA PUBLIC RECORDS LAW
Pursuant to Section 119.0701 of the Florida Statutes, if the Consultant meets the definition of
"Contractor" as defined in Section 119.0701(1)(a), the Consultant shall:
a) Keep and maintain public records that ordinarily and necessarily would be required by
the public agency in order to perform the service;
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 7 of 19
b) Provide the public with access to public records on the same terms and conditions that
the public agency would provide the records and at a cost that does not exceed the cost
provided in this chapter or as otherwise provided by law;
c) Ensure that public records that are exempt or confidential and exempt from public
records disclosure requirements are not disclosed except as authorized by law; and
d) Meet all requirements for retaining public records and transfer to the City, at no City cost,
all public records created, received, maintained and/or directly related to the
performance of this Agreement that are in possession of the Consultant upon
termination of this Agreement. Upon termination of this Agreement, the Consultant
shall destroy any duplicate public records that are exempt or confidential and exempt
from public records disclosure requirements. All records stored electronically must be
provided to the City in a format that is compatible with the information technology
systems of the City.
For purposes of this Article, the term "public records" shall mean all documents, papers, letters,
maps, books, tapes, photographs, films, sound recordings, data processing software, or other
material, regardless of the physical form, characteristics, or means of transmission, made or
received pursuant to law or ordinance or in connection with the transaction of official business of
the City.
Consultant's failure to comply with the public records disclosure requirement set forth in Section
119.0701 of the Florida Statutes shall be a breach of this Agreement.
In the event the Consultant does not comply with the public records disclosure requirement set
forth in Section 119.0701 of the Florida Statutes, the City may, at the City's sole discretion, avail
itself of the remedies set forth under this Agreement and available at law.
[REMAINDER OF THIS PAGE LEFT INTENTIONALLY BLANK]
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 8 of 19
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
by their appropriate officials, as of the date first entered above.
FOR CITY: CITY OF MIAMI BEACH, FLORIDA
ATTEST:
r
By:
Rafadf E. Granado, C', ,elk Philip Le in yor
' � �s:�,�-•-�'••6�� .., Date:
Date: �-
�NrA I ED-
;�''. #"•.. ��;�i� mow°
FOR CONSULTANT: ``���ay '. ••' a - Maria Castillo
To N
ATTEST:
By: �,-
Wtness Con ultant
cx�'S��a r)&n I S IA a n a
Print Name Print Name
Date: Date.
APPROVED AS TO
FORM & LANGUAGE
& FOR EXECUTION
City Attorney r Dote
City of Miami Beach—MARIA CASTILLO
Parent-Child Home Program Page 9 of 19
€
x
f
Ii
RECORD-INTRODUCTION
qy ��,$��t.�.• jg� �'ti Y fig, �R C
n S :
y� c � rit � �tst deny
r, i�7F:E.$YitG `: '➢P irR $ �i 3 r M �' 4 �b x. .°:L a
o�
{
f
}
it .�wxc $ x�flF. hID 5 .' E�;.,. a e_p t�(-� F
,.u,,... ..-, �.. .
❑Almost none ❑Small ❑ Moderate ❑ Large
-7
7,7717 r f
❑Almost none ❑ Small ❑ Moderate ❑ Large
.',riik �ffi4ffMY 'YQ W" 4 ""!� t ? a`n 1 yT
'4;L` .xs-,<-
[]Was on-time and ready for visit w/no distractions ❑Does not hit, poke,bite
[]Gave child directions ❑Initiates positive activities
❑Shows warmth toward child ❑Follows rules/directions
❑Did not yell, nag,or use harmful words Ells creative and inventive
❑Praises and encourages child ❑Attentive and concentrates on activities
❑Parent is firm with child ❑Tolerates delays in having needs met
❑Other: ❑Other: _
"T 1
Y
a
s
` O
H GJ
>74
CO ;.
io
RIF
MIR
f
Si�l.�oo
�4fr Yes
x
t
r
r
WT kz� s7N Mfabt Y`4 +:
a� E
r r
�j
Z W°
o I
CL I
h �
x
^BBC 2"
t
t a
yv
UN a
a
S I :.
szs '
s
"
mn'.
4
sw�s. •.s�:ax. �P.�.x. s
i
i
t
........................... ........
0 4-
vm
ECL m m m m m cu
c c c c c cl
-3 E ❑❑l❑J❑J❑❑
0 0 0 0 0 0
MZIZZZZZ
CL HHHOUH
cri
0 0)
CL '6
co
(D C
E 0
E
0
M M
U. a Z
CL ;;a
Gil
ca m co m Co. ca
C C C c c c
C
u) IEIRF-ILJI:El
D!
a
0 010 0 ol 0 U:
I
I z
> Z zzzz
.-
H Li❑Li❑E]
0 E i z
O
M
z ol
> E-
CL O
(D a) CD
E
0 0
................ .........................................
_.. _.... ___._._ _.._..__................._....._
{
i€
{
N ca tQ! t[i R3 m m m m to t0 (0
CC� Cic C C
co
C C C C C C
❑❑❑❑a❑❑❑ ❑ OF-11 I
to I
Rio: o0000000 0 00
Lziziz�zzzzzz z zz
a?❑❑1010❑❑❑❑❑ ❑ ❑❑
� � I
i
Cf) Cl) U) C/) U) U) C/) U) EA CA U) U) i
v v v v v v v v v v v v I I
❑❑❑❑❑❑❑❑❑ ❑ El El f
E
1
® !0 Cr s
�^
f! CL
END-
3 w N
t
3
I
j
ttI tl� tCf N {� (Q ttf w co co tB (U t0 w m
C C C C C C C C C C C4 C C C C E j
�❑❑❑❑❑❑a❑❑❑❑❑aa❑
1 = C!
c
ii
CD
0 0 0 0 0 0 0 0 0 0 0 0 0 0 05�,
i O > zzzzzzzzzz�zzzzz C;
E❑❑❑❑aa❑❑❑❑❑❑a❑❑ � 3
W = I ;
� o
U} N N fn 0 0 (on j 0 Vl co N (n N N N
•� v N v tD v N vj v! v v v v v v v
❑❑❑❑❑❑❑❑❑;❑❑❑l❑�❑❑ L I
i
i€
d1 ?` a)
w O :
a � v
In
a a 4
.U-
uj
n
0
�.+ " w s
CL
W
Ow Q C' ci • ss i
= o �
Q
O
o
0
cn psi - �-
Q+ 4 Q c
w U °
Q uu Z t7 O .� o
0 El cu
LLJ
�?
U.
Z
® W O w
O D w O tLo Cl) -0 a, is Q o
�7 z Z ° .p " n`A
a
+1 O � N o
d
Q Q °, o o 3 a CL
w cf- s W
to
--e LL O c a o -0 o a =
(� Q a
bD
vii v~i � 'a
N a. a o M
.� �• N alt
V1 O v >
o '> ,> > O
W t �J Q X
t7 C) a' n' ', > O
ui 0
(U o a
in
tii Z O Z _ > �° ca
a +• a� 4n LA v
ate,
L > L E " .D p c
z � o a CL
3
4 Z 4A D eQ -� o
Z N OC 0 a ?p- O y M d O OD
tA L3 m .0
CL
CL 0
0
f
:, ........................................_...................._...._.........._......._._-.................................._...._._.......-........................._.._..............................._._.................................._......___-.........._...................................................._...........................-._......................._._....._........,........_...._........_................................
......................
C).
4,615:i
C%4
�,mgg
RNA
gg' 2c .
-T
VINQ 'f?
px
IN-
C)
.... ........
0
....... ...
2:! W
ty)
k
�wp
mo
0
CL
i13 r Q3 CL
0
. ......... ct)
x
0 0
0
CL
C
(U
4)
A)
"R C�
4-1
0 cu
CL
CO 4-1 (U CA MIS CO C.
u!.Rk 4W
0
0 -C
C.
0
EM
N -+
tlD
>
0
lui
>
4A
S-ybP-'.ffi�'-K,,`.
0
JA
> LLB-0
..........O. 0
CL
o
CL
>
C
0
IA JA
4)
cu A _a
>
>
41
oj
>
0
>
CU m 0
a)
....... 0
C
C
>
ui
0
g
Z 0
.............................................. ...............................
............ ......................................................................
is
is
Ii
a 9° 0
C. N
�0° a
H N
G fII a •>
L U L 'O (J
�g a
s
LU
a !�
E r;
V) = o
w O c K
Q ❑ t
im .� LL u
11 d`
c ,
O .w d CL
ow Q O
Z ❑ O a
W13
C3 = odc
w ° a
_ °
o
ti 'a
W (u•�
ui
z fl. �
z = W � �
tA
�.. Q LU °
J � uj
tto O
® O .ui a o
O C O t v
w m
z :3
W CC o
p N
o IV
a �
U Z +; o o r a
" H
Q w
Q u N > ry t
ca v,
4-1
N a F-
cn O a M
> C O p a o s 4- 4.0 . O @�
F.. Cti' d +-' I- LO O O ..7
%- Y. t 's
_ a o 4-J N
O Qy
tA
tlD
fly
v
+� w O n u V) � p` } a m v ,
u' Z a O �- to
£ Q
uj t i L ?�, s 'Ci =< O O
Z a oQc a -W L o c► c c c
AA
cu
c. A On Imo\I� A a
u d Q Z
G. CL d
LU CL oal 0.
o .❑ o ❑ •�
= p oc an N �r► v
u = a •>
�_...__._._.
Ro
€E
1
? O
si F N
y � i
® kL L
yin.1.•s::
� k
s
t � l
t
' r
r
�y �g
x:
5Sf ':♦
a d':
MRMO
CEO
x„ i
� y i
cn
G •w
; bO
.Sw 4 (�
CL
-a ,a o
lu
N O + } p.
lu
7
�' :�; 'i' C ;yam„ � ''►- � � �'
. 3
;v c
.O 0J fl 4) Q Q
ro � QJ � •Zi � � bA `O `dA.5,� co �` Q-
} L
lu
N N U R7 .��o++„ tC
CA
Ln
CU
'fl � � 'TJ Rf v►
IV 0
N
GJ ��'' � '�3` d, � ••p �- •i � ..� o � >` � fin. ��
1 �, .c,+ ;' � �-+: +.r .� +� +.+ ! +� '•� vas _ +-+ .i.r .►,_ +�; �: ..• v►
DJ ;' tL� G1 fl tU fl dl t� fl N v t3J C N
�. L rt •,A. �. � L-! L. .<i'� L L L E ;` 9 �, L L L L; L :F
w�
}
........
Agency: City of Miami Beach a "
Contract Number: 1428-1090 The Children'sTrust'
Client ID:
Client Name:
Date:
Admin Point 1 2 3 4
Home Literacy Activities*
Por favor, digame cuantas veces en la ultima semana usted o alguien en su hogar ha
hecho alguna de las siguientes:
ZCuantas veces en la ultima semana usted o ENTER NUMBER OF
alguien en su casa ... TIMES PER WEEK
1. Le ha leido a 2
Le ha contado a un
2. cuento?
Le ha ensenado a palabras,
3. letras, o numeros?
s 7' RON.x Yerak
mm
MIN
*To be collected at first visit (First month of contract year 2012-2013 for Carryover
participants) and EVERY SIX (6) MONTHS thereafter.
�nury free C�a{if ian v
f o kids Miami The OW&WSTna
HOME SAFETY CHECKLIST
Participant Name: ID: Date: Staff Name:
•e\.1.ae„ ,•„\\- ,��. \\ a ��x.�:. \�.,,�.. �a ':Z, r`•E 'ism,��\.
`�c•. \YSC c- \ ..!"' ' {( YAK`. #. *;�•„c' _`..
r.. ,\
fir. �. ��..\�,�.e�, ,-. �..�.x`+ a::.`:_.w\\\��F a�..�. �.�x\\\„\,\�.`�,�a� s�.•'�:t:
Do you ever travel with a child in a car without a car seat or a Yes No
booster seat? (1)
1 Too many I am going My child
I don't in the
If the answer is Yes,why? (I) - people P only
a short complains
have one car distance about it
2 Do older children and adults sometimes ride without using a Always Frequently Sometimes Never
booster or seat belt in a car? (include back and front seats) (1)
^.
OR
\31 I R111
Q111 R PRO X.1\11,
31 i 21M
nw
-.. \a?".a: •: t* Y .?W. xl � L \ w ., \ .�`.\\s \.r' \ ?�'S,. •`, \ +x.::•a��. a...
3 Does your baby sleep in a crib? (0) Yes No
4 Does your baby ever sleep on a waterbed,adult bed,
Yes No
beanbag chair or sofa? (1)
5 Is the sleeping area kept simple without soft blankets, Yes No
bumpers,pillows,and stuffed toys? (0)
6 Is your baby put to bed on his/her back to sleep? (1) Always Frequently Sometimes Never
7 Are there curtains or cords dangling or looped near the crib, Yes No
playpen,or other areas of the house?.(0)
Which of the following objects might young children try to put in Pins Balloons Baggies
$ their mouths that could cause them to choke I
() Coins All of the above None of the above
Do you ever get down on the floor of your house and look for
9 potential choking hazards (such as pins,balloons, baggies, Always Frequently Sometimes Never
coins)? (1)
10 Do you check your child's toys for small parts that can fit in their Always Frequently Sometimes Never
mouth? (1)
+\ Y\ ,� �\. �y, �\b a1 \ \ ` * K \
Because drowning can happen in seconds,young children
should not ever be alone in the water,but some parents have
been tempted to"leave for a second"to answer a phone,a
11 doorbell.or get something they forgot.'What do you do to
avoid leaving even for a second?L(I)
Home Visitor's rating of parent's response (Appropriate Somehow
response:11 don't:ever Jea"ve rny"ch�ld,in the tub alone no matter Very appropriate Not appropriate
appropriate
What
12 If there is a pool or a hot tub on your property,Is access limited Yes No N/A
through gates,door alarms,door locks or door knob covers? (1)
If there is a fence or other barrier around the pool,are there
13 chairs or other items nearby a child can climb to get over the Yes No N/A
fence? (0)
(0) Indicates the item should ideally be answered based on the home visitors Observation.
(1) Indicates the questions should be asked to the parent verbatim on an Interview format.
i
Injury Fret coali f ion `..
y, f :. r Kids - Miami 's t
Fires/Sums Answer choices;(Please circle onej:.
14 When was the last time you checked if your smoke detector Last Last 6 months A year I can't
works? (I) week month ago ago remember
15 When was the last time you changed the batteries in your Last Last 6 months A year I can't
smoke detector? (I) week month ago ago remember
Ask parent to demonstrate which stove burners are commonly
16 used and how pot handles are placed.Are pot handles turned Yes No
toward the back of the stove? (0)
Have you checked the temperature of the hot water where you Yes No
live? (1)
17 What is the recommended temperature setting for water
heaters to avoid water burns? (1)
HV's rating of response (Appropriate response: 120 Fahrenheit) Very appropriate Somehow Not appropriate
Appropriate
Do you test the water prior to bathing the child? (1) Yes No
18 If yes, How do you check it? (1)
Somehow
HV's rating of response (Appropriate response:use wrist/hand) Very appropriate Appropriate Not appropriate
19 Does anyone in the house ever fall asleep smoking? (1) Yes No
Fags/Struck by an object Answer choices(Please circle one)
Is there a safe place (such as a crib,playpen,high chair,or
20 stationary activity center) to place the baby when he/she is not Yes No
being held? (0)
21 Are heavy furniture (entertainment centers,cabinets on which Yes No
kids can climb) braced securely? (0)
22 Stairways have gates (for infants and toddlers) and handrails (0) Yes No N/A
23 Do the high chair and sitting toys have a waist and a crotch Yes No N/A
strap? (0)
24 Do you leave the baby alone on tables or beds,even for a brief Always Frequently Sometimes Never
moment? (0)
Poisoning Answer choices(Please circle one)
Are all medicines cleaning supplies,make-up,adult beverages
25 (alcohol and energy drinks),art supplies stored up high and out Yes No
of reach of children or in a locked cabinet)? (0)
26 Are emergency numbers (i.e. Poison Control 1800-222-1222) Yes No
posted on/by your phone? (0)
Gun Safety- Prevention fdvtotlon ONLY Ans;wor ch circle one)
Age-appropriate gun safety statistics and prevention education
27 were provided (including access,storage,locks,separate Yes No
ammunition,etc.)
Genert"afety Away from home An d ch�ai�es Pie�ls�e;,cfrcle one)
28 Do you check for/ask about safety hazards in homes of friends Always Frequently Sometimes Never
or you
where your child may play? (1)
(0) Indicates the item should ideally be answered based on the home visitors Observation.
(1) Indicates the questions should be asked to the parent verbatim on an Interview format.
i