Fillable Form 6: W Z E . . T (ACEs Aware)

Fill Online, Printable, Fillable, Blank Form 6: W Z E . . T (ACEs Aware) Form

Use Fill to complete blank online ACES AWARE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 6: W Z E . . T (ACEs Aware)

On average this form takes 54 minutes to complete

The Form 6: W Z E . . T (ACEs Aware) form is 24 pages long and contains:

  • 0 signatures
  • 1 check-box
  • 216 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your ACEs Aware forms online.

BROWSE ACES AWARE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Cambodian)2020
&
( ( . (
&
6
8 <
( @
A
(
&
.
6
E F
G
H
!"#$!%')*+,-/01',23)4579):);9!=' )
>?'*$!%75*BC /9)D;')
(Pediatric ACEs and Relevant Life Events Screener) (P
EARLS)--,;> (Child)
ស"មាប់បំេពញេដោយអ/កេមើលែថទាំ
!"#$%&'()*+,'.- /0
'123/%$4 '5 !260 +,78- 9:"!;'<=>0 ;
'123/%$45?:!0 !"%*"!5*6@"4"(5AB">.D6'!260 C
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='
!0R,;>4;Q ,#>R-R!4;)5R%!V>X# 4',;>!0R4; ,C-_,#>YL7#';,I ,Y#9)R\='/ P-B*YL,3")Q
,*9),'/b-#;,c# d0P>',;>!0R4;,;*-; ,*,;>!0R4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)[")
,;*,j>? R-!-0k/01',23)'4**$/ )>0L0_)Q !"#!$%&')& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A4
9:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GH631#.483$1KB/!$*+,F&$62!L610B/ % “@&F/3&!N”
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
H ]
.
T ^ ] T
W
^
W W .
H
E
]
. .
.
^ ^ < ` a
.
.
^
O E W .
H
E
]
. .
H
E
] N
E .
A
(
&
T
. .
T ^ l
T
(
&
. . (
l
<
]
(
IJ M
!"#$%& 1
§ '()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3+/E=$F'%?
/ A / A
§ '()0#$EG(@3 '$*+,-./0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
/ I >& /
§ '()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"LSG( 78LX$?S,X( 78LX-(<&,8=P8>+
LX$?S,X( 8>+LX-("2RLSG( PTSD F78LX-(QY:43,8)
/ A > I VW 2R > VW VW >G
>G > VW >G Z
§ '();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-'$*+,-./0#$F'%?
/ /
§ '();<=$8>3:-'+\)(,-./'$*+0#$ F0#$'8)?!@%3AH38*3$123- F-S]C-^5835-NO37389:$3,"_$.=,3 F'J-)@#3'M`5P=.S^3- F@#3'L7a-Na3'JS)5'<$F'%?
/ / # A / A
§ '()'$*+,-./0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3< F8G5435%%9?
$3,!@%3 '56'<?f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
/ / I
A W /
§ '()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@% 3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<MLY:H38#3$'"i+'%j( F'%? ឬ '()'$*+
,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL'E%c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
/ / /
/ b)
§ '()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $Nk$ %c$A'"2`+ F'4dc '4d$089:B3$/'$*+,-./0#$F'%? ឬ '( )835-=Eh?'<M
LY:H38#3$'56$#C+J$=8JE9.3,123-L3:'$*+,-./0#$P23A+'<$ B?/'1'0d:'$*+,-./0#$835 .23$.#38 FJ(KL,-9.F'%? ឬ '()835-=Eh?'< MLY:H38#3$
'56$#C+J$=8JE9.3,123-EJ838'$*+,-./0#$ FJ-J<_(B3$ !B?435'1'0d: '$*+,-./0#$P23S@3 <9$'E03SJ(KL435'143-F'%?
/ / / b&
/ / b) /
/ > / b) b)
§ '()'$*+,-./0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$435-mc'$*+,-./0#$ F. '0d:'$*+,-./0#$-mc-=E?'5dc (38,'-j-
!B?<S+/435 F'1'0d: '$*+,-./0#$83503,8*H8G5J.9? F0#$H38#3$123--m=5-m+ F123-435,98'Q%(3883(/ (38,5nEK@ F(38,5n':d5 7389:'$*+
,-./0#$F'%?
/ I / =A h
=A b) I / / / &
§ '()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$%A5+,-./0#$'8)?!@%3A,-./'$*+0#$F'%? T%3U,H ;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 F
oBEK'.#U3435',)SK?8$'56 F',)'SM'%6F'%?
/ / =A / I
0;L,-# “"1/dR” V>X# R?90Bm;1-#n
T N
. W E
]
.
^
R-0),U9>,1p* R?90R
%!BC/,iR/Q
T A o
E W
^
E
Child (Pa
rent/Caregiver Report) – Deidentified
!
!"#$%& 2
§ '()'$*+,-./0#$123-'D)M ? F123-730#$,+'JEdco50A'<UG+i3'56$#C+QK8p35 .UE85 F.3?3,-./0#$F'%? (T%3U,HIJ(KL435'E.82C('143- -A<35 F
.$8*Q3<UG+i3'"i+q'%j( .r+h38 FQ3,L$8)
/ W / ) G I b)
*
§ '()'$*+,-./0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HJ(KL435'E,lP35 F'1'0d:83503,8*H03-/'0d5 F8G5,3-/-N]R? 'Bd:.3,!(<K708^R, 73(G
.3.5 0(>.Ns3H'Q% %A'5d,"2RL'Q% .3.53 Q3< P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I I b) I
I
§ '()'$*+,-./0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"tc'56 $3,8G5835$!52+pG('@,'B)8^.#3$/'56 435',)$!52+'JS)573+<&,B+'56$#C+
,:u'<?J43A89:!P 435J-f88=P5_+$3,-'HvM'SM F$3,,w-0K. FJ(KL!(,./'567389:J$=8JE9.3,73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I &
/
§ '()0#$123-43,8Z@3 '$*+,-./0#$8G58358OR-JE-/JE35 'B)8^MC3 F@38OR-.J83-/'$*+,-. /0#$5_+0./8=5'<?0#$03S%GM!@8 '%j(?
/ / & A
§
'()'$*+,-./0#$123-435!-$<&;<=$8>3: F0#$'8)?!@%3A 'Bd:.3,!($3,SGN]_8-'Hvdc03.5 FSAHx?J.=$?
/ #
§ '()'$*+,-./0#$123-435,. /'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+ $3:1V5/1V, F<G$3,Q3<?
/ VW
§
'()$K5,-./0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'% ?
/ /
0;L,-# “"1/dR” R?90Bm;1'!n
T N
. E
]
. .
Child (Parent/Caregiver Report) – Deidentified
Cambodian)2020
Cambodian)2020
!"#$!%')*+,-/01',23)4579):);9!=' )>?'*$!%75*BC/9)D;')
(Pediatric ACEs and Relevant Life Events Screener) (P
EARLS)--,;> (Child)
&
( ( . (
&
6
8 <
( @
A
(
&
.
6
E F
G
H
ស"មាប់បំេពញេដោយអ/កេមើលែថទាំ
!"#$%&'()*+,'.- /0
'123/%$4 '5 !260 +,78- 9:"!;'<=>0;
'123/%$4 ?5 :!0 !"%*"!5*6@"4"(5AB">.D6'!260C
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='
!0R,;>4;Q ,#>R-R!4;)5R%!V>X# 4',;>!0R4; ,C-_,#>YL7#';,I ,Y#9)R\='/ P-B*YL,3")Q
,*9),'/b-#;,c# d0P>',;>!0R4;,;*-; ,*,;>!0R4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)[")
,;*,j>? R-!-0k/01',23)'4**$/ )>0L0_)Q !"#!$%&')& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A4
9:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GHIJ631#.483$1KB/!$*+,F&$62!L610B/ % “@&F/3&!N”
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
H ]
.
T ^ ] T
W
^
W W .
H
E
]
. .
.
^ ^ < ` a
.
.
^
O E W .
H
E
]
. .
H
E
] N
E .
A
(
&
T
. .
T ^ l
T
(
&
. . (
l
<
]
(
M
!"#$%& 1
.K8EK. "43%/S3." !B? J(KL5_+.AHy,z
§
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3A+/E=$F'%?
/ A /
43%/S3.
☐
'%
☐
§
'()0#$EG(@3 '$*+,-./0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
/ I >& /
43%/S3.
☐
'%
☐
§
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"2RLSG( 78LX$?S,X( 78
LX-(<&,8=P8>+LX$?S,X( 8>+LX-("2RLSG( PTSD F78LX-(QY:43,8)
/ A > I VW > VW VW
>G >G > VW >G Z
43%/S3.
☐
'%
☐
§
'();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-'$*+,-./0#$F'%?
/ /
43%/S3.
☐
'%
☐
§ '();<=$8>3:-'+\)(,-./'$*+0#$ F0#$'8)?!@%3AH38*3$123- F-S]C-^5835-NO37389:$3,"_$.=,3 F'J-)@#3'M`5 P=.S^3- F@#3'L7a-Na3
'JS)5'< $F'%?
/ / # A / A
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 85J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3<
F8G5435%%9?$3,!@%3 '56'<?f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
/ / I G
A W /
43%/S3.
☐
'%
☐
§
'()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@% 3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<MLY:H38#3$'"i+'%j(F
'%? ឬ '()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@% 3AJ(KL'E%c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
/ / /
/ b)
43%/S3.
☐
'%
☐
§
'()835-=E?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $Nk$ %c$A'"2`+ F'4dc'4d$089:B3$/'$*+,-./0#$F'%? ឬ
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123-L3:'$*+,-./0#$P23A+'< $ B?/'1'0d:'$*+,-./0#$835 .23$.#38 FJ(KL,-9.F'%? ឬ
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123-EJ838'$*+,-./0#$ FJ-J<_(B3$ !B?435'1'0d:'$*+,-./0#$P23S@3 <9$'E03SJ(KL
435'143-F'%?
h / / / b&
/ / b)
/ / > / b)
b)
43%/S3.
☐
'%
☐
§
'()'$*+,-./0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$435-mc'$*+,-./0#$ F. '0d:'$*+,-./0#$-mc-=Eh?
'5dc ( 38 ,'-j-!B?<S+/435 F'1'0d:'$*+,-./0#$83503,8*H8G5J.9? F0#$H38#3$123--m=5-m+ F123-435,98'Q%(3883(/ (38,5n
EK@ F(38,5n':d5 7389:'$*+,-./0#$F'%?
/ I / =A
=A b) I / / /
&
43%/S3.
☐
'%
☐
§ '()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$%A5+,-./0#$'8)?!@%3A,-./'$*+0#$F'%? T%3U ,HI
/ / =A /
§ ;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 FoBEK'.#U3435',)SK?8$'56 F',)'SM'%6F'%?
43%/S3.
☐
'%
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 1?
. Z
< H ] N
.
]
<
]
.
R-0),U9
>,1p* R?90R%!BC/,iR/Q
T A o
E W
^
E
Child (Parent/Caregiver Report) – Identified
!
!"#$%& 2
.K8EK. "43%/S3." !B? J(KL5_+.AHy,z
§ '()'$*+,-./0#$123-'D)M ? F123-730#$,+'JEdco50A'<UG+i3'56$#C+QK8p35 .UE85 F.3?3,-./0#$F'%? (T%3U,HIJ(KL435
'E.82C('143- -A<35 F.$8*Q3<UG+i3'"i+q'%j( .r+h38 FQ3,L$8)
/ W / ) G I
b) *
43%/S3.
☐
'%
☐
§
'()'$*+,-./0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HJ(KL435'E,lP35 F'1'0d: 83503,8*H03-/'0d5 F8G5,3-/-N]R? 'Bd:
.3,!(<K708^R, 73(G.3.5 0(>.Ns3H'Q% %A'5d,"2RL'Q% .3.53 Q 3< P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I I b) I
I
43%/S3.
☐
'%
☐
§
'()'$*+,-./0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"tc'56 $3,8G5835$!52+pG('@,'B)8^.#3$/'56 435',)
$!52+'JS)573+<&,B+'56$#C+,:u'<?J43A89:!P 435J-f88=P5_+$3,-'HvM'SM F$3,,w-0K. FJ(KL!(,./'567389:J$=8
JE9.3,73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I &
/
43%/S3.
☐
'%
☐
§ '()0#$123-43,8Z@3 '$*+,-./0#$8G58358OR-JE-/JE35 'B)8^MC3 F@38OR-.J83-/'$*+,-./0#$5_+0./8=5'<?0#$03S%GM!@8
'%j(?
/ / & A
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$123-435!-$<&;<=$8>3: F0#$'8)?!@%3A 'Bd:.3,!($3,SGN]_8-'Hvdc03.5 FSAHx?J.=$?
/ #
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+ $3:1V5/1V, F<G$3,Q3<?
/ VW
43%/S3.
☐
'%
☐
§ '()$K5,-./0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'%?
/ /
43%/S3.
☐
'%
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 2?
. Z
< H ] N
.
]
<
]
.
Chi
ld (Parent/Caregiver Report) – Identified
Cambodian)2020
Cambodian)2020
!"#$!%')*+,-/01',23)4579):);9!=' )>?'*$!%75*BC/9)D;')
(Pe
diatric ACEs and Relevant Life Events Screener) (PEARLS)--!"#$
!%H?904;,-/BJK,;>
(Teen Caregiver Report)
&
( ( . (
&
6
8 <
( @
A
(
&
.
6
E F
G
&
E
I
. L
M
ស"មាប់បំេពញេដោយអ/កេមើលែថទាំ
!"#$%&'()*+,'.- /0
'123/%$4 '5 !260 +,78- 9:"!;'<=>0;
'123/%$4 ?5 :!0 !"%*"!5*6@"4"(5AB">.D6'!602C
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!# S,' /#!,U 01',23)V>X# YL0[D/R\=' )>R\9/='
!0R,;>4;Q ,#>R-R!4;)5R%!V>X# 4',;>!0R4; ,C-_,#>YL7#';,I ,Y#9)R\='/ P-B*YL,3")Q
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
H ]
.
T ^ ] T
W
^
W W
.
H
E
]
. .
.
^ ^ < ` a
.
,*9),'/b-#;,c# d0P>',;>!0R4;,;*-; ,*,;>!0R4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)[")
,;*,j>? R-!-0k
/01',23)'4**$/ )>0L
0_)Q !"#!$%&'()& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A4
9:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GHIJ631#.483$1KB/!$*+,F&$62!L610 B/ % “@&F/3&!N”
.
^
O E W .
H
E
]
. .
H
E
] N
E .
A
(
&
T
. .
T ^ l
T
(
&
. . (
l
<
]
M
!"#$%& 1
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3A+/E=$F'%?
'()0#$EG(@3 '$*+,-./0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"2RLSG( 78LX$?S,X( 78LX-(<&,8=P8>+LX$?S,X(
8>+LX-("2RLSG( PTSD F78LX-(QY:43,8)
'();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-'$*+,-./0#$F'%?
'();<=$8>3:-'+\)(,-./'$*+0#$ F0#$'8)?!@%3AH38*3$123- F-S-^5#835-NO37389:$3,"_$.=,3 F'J-)@#3'M `5P=.S^3- F@#3'L7a-Na3'JS)5'<$F'%?
'()'$*+,-./0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3< F8G5435%%9?$3,!@%3
'56'<?f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
'()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@% 3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<MLY:H38#3$'"i+'%j(F'%? ឬ '()'$*+,- ./0#$
123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL'E %c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $N$ %c$A'"2`+ F'4 dc'4d$089:B3$/'$*+,-./0#$F'%? ឬ '()835-=Eh?'<MLY:
H38#3$'56$#C+J$=8JE9.3,123-L3:'$*+,-./0#$P23A+'<$ B?/'1'0d:'$*+,-./0#$835 .23$.#38 FJ(KL,-9.F'%? ឬ '()835-=Eh?'<MLY:H38#3$'56$#C+J$=8
JE9.3,123-EJ838'$*+,-. /0#$ FJ-J<_(B3$ !B?435'1'0d:'$*+,-./0#$P23S@3 <9$'E03SJ(KL435'143-F'%?
'()'$*+,-./0#$123-/J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,HI 0#$H38#3$/435-mc'$*+,-./0#$ F.=A '0d:'$*+,- ./0#$-mc-=Eh?'5dc (38,'-j- !B?<=AS+/
435 F'1'0d:'$*+,-./0#$83503,8*H8G5J.9? F0#$H38#3$123--m=5-m+ F123-435,98'Q%(3883(/ (38,5nEK@ F(38,5n':d5 7389:'$*+,-./0#$F'%?
'()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$/%A5+,-./0#$'8)?!@%3A,-./'$*+0#$F'%? T%3U,H ;<=$8>3:/0#$'8)?!@% 3A435!?+ ?c F!-$E#3 FoBEK
'.#U3435',)SK?8$'56 F',)'SM'%6F'%?
0;L,-# “"1/dR” V>X# R?90Bm;1-#n
T N
. W E
]
.
^
R-
0),U9>,1p* R?90R%!BC/,iR/Q
T A o
E W
^
E
Teen (Parent/Caregiver Report) – Deidentified
!
!"#$%& 2
'()'$*+,-./0#$123-'D)M ? F123-730#$,+'JEdc o5 0A'<UG+i3'56$#C+QK8p35 .UE85 F.3?3,-./0#$F'%? (T% 3U,HIJ(KL435'E.82C('143- -A<35 F
.$8*Q3<UG+i3'"i+q'%j( .r+h38 FQ3,L$8)
/ W / ) G I b)
*
'()'$*+,-./0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HIJ(KL435'E,lP35 F'1'0d:83503,8*HI03-/'0d5 F8G5,3-/-N]R? 'Bd:.3,!(<K708^R, 73(G.3.5
0(>.Ns3H'Q% %A'5d,"2RL'Q% .3.53 Q3<P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I b) I
'()'$*+,-./0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"tc'56 $3,8G5835$!52+pG('@,'B)8^.#3$/'56 435',)$!52+'JS)573+<&,B+'56$#C+,:u
'<?J43A89:!P 435J-f88=P5_+$3,-'HvM'SM F$3,,w-0K. FJ(KL!(,./'567389:J$=8JE9.3,73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I &
/
'()0#$123-43,8Z@3 '$*+,-./0#$8G58358OR-JE-/JE35 'B)8^MC3 F@38OR-.J83-/'$*+,-./0#$5_+0./8=5'<?0#$03S%GM!@8 '%j(?
/ / & A
'()'$*+,-./0#$123-435!-$<&;<=$8>3: F0#$'8)?!@%3A 'Bd:.3,!($3,SGN8-'Hvdc03.5 FSAHx?J.=$?
/ ]_ #
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+ $3:1V5/1V, F<G$3,Q3<?
/ VW
'()$K5,-./0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'%?
/ /
'()'$*+,-. /0#$123-/J(KL435D%=$ S3-P2{5 F73-/E=$F'%?
=A /
'()'$*+,-./0#$123-J(KL435'E-A<35P3+,3+$3: F<3$|.AB F$3,EJ838< oBEK'.#U3 (T%3U,H 8G(J-=. 8G(J.) F'%?
/ & & I > > &
0;L,-# “"1/dR” R?90Bm;1'!n
T N
. E
]
. .
Teen (Parent/Caregiver Report) – Deidentified
!
Cambodian)2020
Cambodian)2020
!"#$!%')*+,-/01',23)4579):);9!=' )>?'*$!%75*BC/9)D;')
(Pediatric ACEs and Relevant Life Events Screener)
(PEARLS)--!"#$!%R?904;,-/BrV,;>
(Teen Caregiver Report)
ស"មាប់បំេពញេដោយអ/កេមើលែថទាំ
&
( ( . (
&
6
8 <
( @
A
(
&
.
6
E F
G
&
E
]
. W
H
!"#$%&'()*+,'.- /0
'123/%$4 '5 !260 +,78- 9:"!;'<=>0 ;
'123/%$4 ?5 :!0 !"%*"!5*6@"4"(5AB">.D6'!260 C
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='
!0R,;>4;Q ,#>R-R!4;)5R%!V>X# 4',;>!0R4; ,C-_,#>YL7#';,I ,Y#9)R\='/ P-B*YL,3")Q
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
H ]
.
T ^ ] T
W
^
W W .
H
E
]
. .
.
^ ^ < ` a
.
,*9),'
/b-#;,c# d0P>',;>!0R4;,;*-; ,*,;>!0R4;e0,fg h9)5*9) ,i,' /01',23)CL*,U,)[")
,;*,j
>? R-!-0k/01',23)'4**$/ )>0L0_)Q !"#!$%&')& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A4
9:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GH631#.483$1KB/!$*+,F&$62!L610B/% “@&F/3&!N”
.
^
O E W .
H
E
]
. .
H
E
] N
E .
A
(
&
T
. .
T ^ l
T
(
&
. . (
l
<
]
(
IJ M
9:;<FO 1
!"#%"! "@&F/3&!" 9='2>"?0J6!$*+,N
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3A+/E=$F'%?
/ A /
43%/S3.
☐
'%
☐
'()0#$EG(@3 '$*+,-./0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J. ?3M/ 5G+/F8G5J(KL435$3,<3,F'%?
/ I >&
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"2RLSG( 78LX$?S,X(
78LX-(<&,8=P8>+LX$?S,X( 8>+LX-("2RLSG( PTSD F78LX-(QY:43,8)
/ A > I VW > VW
VW >G >G > VW >G Z
43%/S3.
☐
'%
☐
'();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-'$*+,-./0#$F'%?
/ /
43%/S3.
☐
'%
☐
'();<=$8>3:-'+\)(,-./'$*+0#$ F0#$'8)?!@%3AH38*3$123- F-S]C-^5835-NO37389:$3,"_$.=,3 F'J-)@#3'M`5 P=.S^3- F@#3'L7a-Na3
'JS)5'< $F'%?
/ / # A / A
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835
.=L(eGQ3< F8G5435%%9?$3,!@%3 '56'<?f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
/ / I
A W /
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@% 3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<MLY:H38#3$'"i+
'%j(F'%? ឬ '()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL'E %c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
/ / /
/ b)
43%/S3.
☐
'%
☐
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $Nk$ %c$A'"2`+ F'4dc '4d$089:B3$/'$*+,-./0#$F'%? ឬ
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123-L3:'$*+,-./0#$P23A+'< $ B?/'1'0d:'$*+,-./0#$835 .23$.#38 FJ(KL,-9.F'%? ឬ
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123-EJ838'$*+,-./0#$ FJ-J<_(B3$ !B?435'1'0d:'$*+,-./0#$P23S@3 <9$'E03S
J(KL435'143-F'%?
/ / / b&
/ / b)
/ / > / b)
b)
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$/435-mc'$*+,-./0#$ F. '0d:'$*+,-./0#$-mc
-=Eh?'5dc (38,'-j-!B?<S+/435 F'1'0d:'$*+,-./0#$83503,8*H8G5J.9? F0#$H38#3$123--m=5-m+ F123-435,98'Q%(3883(/
(38,5nEK@ F(38,5n':d5 7389:'$*+,-./0#$F'%?
/ I =A
=A b) I / / /
&
43%/S3.
☐
'%
☐
'()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$%A5+,-./0#$'8)?!@%3A,-./'$*+0#$F'%? T%3U,H
;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 FoBEK'.#U3435',)SK?8$'56 F',)'SM'%6F'%?
/ / =A / I
43%/S3.
☐
'%
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 1?
. Z
< H ] N
.
]
<
]
.
R-0),U9
>,1p* R?90R%!BC/,iR/Q
T A o
E W
^
E
Teen (Parent/Caregiver Report) – Identified
!
9:;<FO 2
!"#%"! "@&F/3&!" 9='2>"?0J6!$*+,N
'()'$*+,-./0#$123-'D)M ? F123-730#$,+'JE dco50A'<UG+i3'56$#C+QK8p35 .UE85 F.3?3,-./0#$F'%? (T%3U,HIJ(KL435'E
.82C('143- -A<35 F.$8*Q3<UG+i3'"i+q'%j( .r+h38 FQ3,L$8)
/ W / ) G I
b) *
43%/S3.
☐
'%
☐
'()'$*+,-./0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HJ(KL435'E,lP35 F'1'0d:83503,8*H03-/'0d5 F8G5,3-/-N]R? 'Bd:.3,
!(<K708^R, 73(G.3.5 0(>.Ns3H'Q% %A'5d,"L'Q% .3.53 Q 3< P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I I b) I
I 2R
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"tc'56 $3,8G5835$!52+pG('@,'B)8^.#3$/'56 435',)
$!52+'JS)573+<&,B+'56$#C+,:u'<?J43A89:!P 435J-f88=P5_+$3,-'HvM'SM F$3,,w-0K. FJ(KL!(,./'567389:J$=8JE9.3,
73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I &
/
43%/S3.
☐
'%
☐
'()0#$123-43,8Z@3 '$*+,-./0#$8G58358OR-JE-/JE35 'B)8^MC3 F@38OR-.J83-/'$*+,-./0#$5_+0. /8=5'<?0#$03S%GM!@8'%j(?
/ / & A
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-435!-$<&;<=$8>3: F0#$'8)?!@%3A 'Bd:.3,!($3,SGN]_8-'Hvdc03.5 FSAHx?J.=$?
/ #
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+ $3:1V5/1V, F<G$3,Q3<?
/ VW
43%/S3.
☐
'%
☐
'()$K5,-./0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'% ?
/ /
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-/J(KL435D%=$ S3-P2{5 F73-/E=$F'%?
=A /
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-/J(KL435'E-A<35P3+,3+$3: F<3$|.AB F$3,EJ838< oBEK'.#U3 (T%3U,H 8G(J-=. 8G(J.) F'%?
& & I > > &
43%/S3.
☐
'%
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 2?
. Z
< H ] N
.
]
<
]
.
Tee
n (Parent/Caregiver Report) – Identified
!
Cambodian)2020
Cambodian)2020
"#$%"&(*+,-.012(-34*568:*;*<:">( *?@(+%"&86+CD0:*E<(*
(Pediatric ACEs and Relevant Life Events Screener) (PEAR
LS)---<? ("#$%"&J@:1K*N?)
(Teen (Self Report))
'
) ) / )
'
7
9 =
) A
B
)
'
/
7
F G
H
I
'
F
L
M
ស"មាប់បំេពញេដោយអ/កជម7ឺ
កាលបរិេចទៃថេន- ះ៖) ៃថែខ- ឆ:ាកំេណើត៖ ំ
េឈ2ោះរបស អ់ :ក៖
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='!0R
4;Q ,#>R-R!4;)5R%!V>X#4';)!0R4; ,C-_,#>YL7#4; ,Y#9)R\='/ P-B*YL,3")Q
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
]
.
T ^ ] T
W
^
W W .
T
E
]
. .
.
^ ] < ` a
.
,*9),'/b-
#;,c# d0P>'4;,;*-; ,*4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)["),;*
,j>? !"#,7#
AHIP'AFKQ1!BR0KOG>O><&' 0Q6A3ITAU0;N !"#!$%&'()& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8
“C” 1A49:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GHIJ631#.483$1KB/!$*+,F&$62!L6% “@&F/3&!N”
.
^
O E W .
]
. .
] N
E .
A
(
&
T
.
.
S
M
9:;<FO 1
'()0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3A+/E=$F'%?
/ A /
'()0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
/ I >& /
'()0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"2RLSG( 78LX$?S,X( 78LX-(<&,8=P8>+LX$?S,X( 8>+LX-("2RL
SG( PTSD F78LX-(QY:43,8)
/ A > I VW > VW VW >G >G
> VW >G Z
'();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-0#$F'%?
/ /
'();<=$8>3:-'+\)(,-./0#$ F0#$'8)?!@% 3AH38*3$123- F-S]C-^5835-NO37389:$3,"_$.=,3 F'J-)@#3'M`5P=.S^3- F'J-)@#3'L7a-Na3'JS)5'<$F'%?
/ / # A / A
'()0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3< F8G5435%%9?$3,!@%3 '56'<?
f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
/ / I A
W /
'()0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<M LY:H38#3$'"i+'%j(F'%? ! '()0#$123-'D)M F?W;<=$
8>3:/0#$'8)?!@%3AJ(KL'E%c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
/ / / /
b)
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $Nk$ %c$A'"2`+ F'4dc '4d$089:B3$/0#$F'%? ! '()835-=Eh?'<MLY:H38#3$'56$#C+
J$=8JE9.3,123-L3:0#$P23A+'<$ B?/'1'0d:0#$835.23$.#38 FJ(KL,-9.F'%? ! '()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123-435EJ838$A!U+0#$ F435
J-J<_(B3$ !B?435'1'0d:0#$P23S@3 'E03S'143-0#$F'%?
/ / / b& /
/ b) / /
> / b) b)
'()0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$435-mc0#$ F.'0d:0#$-mc-=Eh?'5dc (38,'- j-!B?<S+/435 F'1'0d:0#$835
03,8*H8G5J.9? F0#$H38#3$123--5-m+ F123-435,98'Q%(3883(/ (38,5nEK@ F(38,5n':d5 7389:0#$F'%?
/ I / =A =A b)
I / / m= / &
'()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$%A5+,-. /0#$'8)?!@%3A,-./0#$F'%? T%3U,H ;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 FoBEK'.#U3435
',)SK?8$'56 F',)'SM'%6F'%?
/ / =A / I
0;L,-# “"1/dR” V>X# R?90Bm;1-#n
T N
. W E
]
.
^
R-0),U9>,1p* R
?90R%!BC/,iR/Q
T A o
E W
^
E
Teen (Self Report) – Deidentified
!
9:;<FO 2
'()0#$123-'D)M ? F123-730#$,+ 'JE dc o5 0A'<UG+i3'56$#C+QK8p35 .UE85 F.3?3,-./0#$F'%? (T% 3U,HIJ(KL435'E.82C('143- -A<35 F.$8*Q3<
UG+i3'"i+q'%j( .r+h38 FQ3,L$8)
/ W / ) G I b)
*
'()0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HJ(KL435'E,lP35 F'1'0d:83503,8*H03-/'0d5 F8G5,3-/-N]R? 'Bd:.3,!(<K708^R, 73(G.3.5
0(>.Ns3H'Q% %A'5d,"2RL'Q% .3.53 Q3<P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I I b) I I
'()0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"tc'56 $3,8G5835$!52+pG('@,'B)8^.#3$/'56 435',)$!52+'JS)573+<&,B+'56$#C+,:u'<? J43A89:
!P 435J-f88=P5_+$3,-'HvM'SM F$3,,w-0K. FJ(KL!(,./'567389:J$=8JE9.3,73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I &
/
'()0#$123-43,8Z@3 0#$8G58358OR-JE-/JE35/'B)8^MC3 F@38OR-5_+0./8=5'<?0#$ F;<=$8>3:/0#$'8)?!@% 3A,- ./0#$03S%GM!@8'%j(?
/ & A
'()0#$123-435!-$<&;<=$8>3:,-.0#$ F0#$'8)?!@%3A 'Bd:.3,!($3,SGN]_8-'Hvdc03.5 FSAHx?J.=$?
/ / #
'()0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+$3:1V5/1V, F<G$3,Q3<F'%?
/ VW
'()0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'%?
/ /
'()0#$123-J(KL435D%=$ S3-P2{5 F73-/E=$F'%?
/ =A /
'()0#$123-J(KL435'E-A<35P3+,3+$3: F<3$|.AB F$3,EJ838<&oBEK'.#U3 (T%3U,H 8G(J-=. 8G(J.) F'%?
/ & I > > &
0;L,-# “"1/dR” R?90Bm;1'!n
T N
. E
]
. .
Teen (Self Report) – Deidentified
Cambodian)2020
Cambodian)2020
"#$%"&(*+,-.012(-34*568:*;* <:">( *?@(+%"&86+CD0:*E<(*
(Pediatric ACEs and Relevant Life Events Screener)
(PEARLS)---<? ("#$%"&J@:1K*N?)
(Teen (Self Report))
'
) ) / )
'
7
9 =
) A
B
)
'
/
7
F G
H
I
'
F
L
M
ស"មាប់បំេពញេដោយអ/កជម7ឺ
កាលបរិេច)ទៃថេន- ះ៖ ៃថែខ- ឆ:ាកំេណើត៖ ំ
េឈ2ោះរបស អ់ :ក៖
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='!0R
4;Q ,#>R-R!4;)5R%!V>X# ,C-_,#>YL7#4; ,Y#9)R\='/ P-B*YL,3")Q ,*9),'/b-#;,c#
d0P>'4;,;*-; ,*4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)["),;*,j>? !"#,7#AHIP'AFKQ1!BR0KOG>O><&'
0Q6A3ITAU0;N !"#!$%&')& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A49:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!”
GHIJ631#.483$1KB/!$*+,F&$62!L6% “@&F/3&!N”
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
]
.
T ^ ] T
W
^
W
. .
.
^ ] < ` a
. .
^
O
E W .
]
. .
] N
E .
A
(
&
T
. .
S
(
M
9:;<FO 1
!"#%"! "@&F/3&!" 9='2>"?0J6!$*+,N
1>4G;<R.&A@&0,!(10V5&#78WKL<#X&8/G;<1#4'9)F& 9='R.&A@&010V<;T6<90.6YL$Y&$6/%L<C1F?
( $ (
@&F/3&!
☐
1F
☐
1>4G;<R.&A#&0G&,#Z*)& #Q02>"?@&0%&$2F #Q0@&0FF7'<2!'&[ 0Q6/C#Q02>"?@&0<&,K&,C1F?
( S XO (
@&F/3&!
☐
1F
☐
1>4G;<R.&A@&0,!(10V5&#78WKL<#X&8/G;<1#4'9)F& 9='#&0AH\&!L-]&K:.P?3Q>? (^F&_,* 5#?aA>XQ:.P?3Q> 5#?a<'
3,a> 5#?aA>KO,#L-#X6?a<'3,a> #X6?aA>:.P?3Q> PTSD C5#?aA>]b8@&,#)
( $ X S `M X `M
`M XQ XQ X `M XQ c
@&F/3&!
☐
1F
☐
1>4WKL<#X&8/G;<1#4'9)F&$R.&A2A#&) 1#4'6&8 CA6d&AG;<C1F?
( (
@&F/3&!
☐
1F
☐
1>4WKL<#X&8A16e4>,A!(G;< CG;<1#4'9)F&$*&#Z&<R.&A CA3ITAU0#&0AH\&5&#78<&,:J<!L,& C12A4);&1[f0-L!3U&A C
12A4);&1?5gAHg&123401K<C1F?
( ( ; $ (
$
@&F/3&!
☐
1F
☐
1>4G;<R.&A-h/-&><&,9)F&$!#2!A 1=B8G;<1#4'9)F&$*&#;&< (^F&_,* #Q02>"?@&0<&,K&,KO!i&0]&K9='#Q0#&0
!L?>iQ]&K C#Q0@&0FF7'<&,9)F& 10V1K' j C#&0,A7! 1FB/5&1K'10B/#&0R0R&0:X'5"0<k1=B8)?
( ( S
$ M (
@&F/3&!
☐
1F
☐
1>4G;<R.&A1Y4[ C'MWKL<#X&8/G;<1#4'9)F&$2>"?@&01%92!<=&< 15 2A#&) 1#4'6&81=B8AL%l'1K[?b8*&#;&<
1:m61Fn>C1F? h 1>4G;<R.&A1Y4[ C'MWKL<#X&8/G;<1#4'9)F &$2>"?1%F/<$1:.f6 F&>( =&'( C?&8 C1R@&A1=B8G&?LRC
1F?
( ( (
( h4
@&F/3&!
☐
1F
☐
1>4#&0AL%l'1K[?b8*&#;&<10V<;T62<L#2%7!&,R.&A C5&[J<[&A(@&0,L[ <Ho< F/<$1:.f6 C1@B/1@B<G#78=&<(G;<C
1F? h 1>4#&0AL%l'1K[ ?b8*&#;&<10V<;T62<L#2%7!&,R.&A?&8G;<-.&$61K< = '(1R1GB8G;<#&0!.&<!;&# C2>"?,A7!C
1F? h 1>4#&0AL%l'1K[?b8*&#;&<10V<;T62<L#2%7!&,R.&A@&0%2#&#<$9_6G;< C@&02A2KJ>=&< 9='@&01R1G B8G;<
-.&3)& 1%G&31R@&AG;<C1F?
( ( ( hO
( ( h4
( ( X ( h4
h4
@&F/3&!
☐
1F
☐
1>4G;<R.&A2>"?@&01%,p1'B]A$K&0-&6:.P?1]FC1F? ^F&_,* G;<*&#;&<@&0Aq/G;< C!1GB8G;<Aq/AL%l'10B/ >&#
,1AnA9='K36(@&0 C1R1GB8G;<#&0G&,#Z*#Q02!7' CG;<*&#;&<(R.&AAqL0Aq6 CR.&A@&0,7#1]F>&##&>( >&#,0r%")
C>&#,0r18B0 5&#78G;<C1F?
( S ( L$
L$ h4 S ( (
O
@&F/3&!
☐
1F
☐
1>4R.&A#&0<&,:.&!AXP,R$= 10V<;T6!i&0]&KF$0&<F$06,A!(G;<1#4'9)F&$,A!(G;<C1F? ^F&_,* WKL<#X&8/G;<1#4'
9)F&$@&09'6'/ C9A<%;& CD=%"1!;_&@&01,43"'#<10 V C1,413[1FVC1F?
( ( L$ ( S
@&F/3&!
☐
1F
☐
,*9) ""1/dR" 0q) BC /4;"),M#,i;>Bm;1 1?
. Z
< H ] N
.
]
<
]
.
R-0),U9
>,1p* R?90R%!BC/,iR/Q
T A o
E W
^
E
Teen (Self Report) – Identified
9:;<FO 2
!"#%"! "@&F/3&!" 9='2>"?0J6!$*+,N
1>4G;<R.&A1Y4[ ' CR.&A5&G;<,612%B/D0G$1K_Q6m&10V<;T6]"#s&0 !_%#0 C!&'&,A!(G;<C1F? (^F&_,*S2>"?
@&01%!#.T>1R@&A A$K&0 C!<#Z]&K_Q6m&1:m6t1Fn> !u6l&# C]&,?<#)
( M ( 4 Q S
h4 Z
@&F/3&!
☐
1F
☐
1>4G;<#&0AFKQ1!BR00"?<&,1,4!1G46 (^F&_,*2>"?@&01%,p-&0 C1R1GB8#&0G&,#Z*G&A(1GB0 C#Q0,&A(AHIP' 1=B8
!&,9>K"5G#UP, 5&>Q!&!0 G>X!Hv&*1]F F$10B,:.P?1]F !&!0& ]&K-L!%;&D0<&,1,n0!"2> CKQ<&,]&K) C1F?
S S h4 S
S
@&F/3&!
☐
1F
☐
1>4G;<R.&A#&0AH\& 5&#78<&,!;&<10V (^F&_,* <&,#Q0#&0:w/10V <&,#Q0#&0<90.6sQ>1),1=4#U!;&<(10V @&01,4
<90.612305&6KO,=610V<;T6,8x1K'2@&$#789- @&02A j##L-0J6<&,A1*y[13[ C<&,,zAG"! C2>"?9>,!(10V5&#78
2<L#2%7!&,5&12340 C!#&5Q<2%7!&,5&123400&<) C1F?
( ( S O
4
(
@&F/3&!
☐ ☐
1F
1>4G;<R.&A@&,#c)& G;<#Q0#&0#\PA2%A(2%&0(1=4#UO[T& C)&#\PA0J6G!(#L01K'G;< CWKL<#X&8/G;<1#4'9)F&$,A!(
G;<G&3FQ[9)# 1Fn>?
( $
@&F/3&!
☐
1F
☐
1>4G;<R.&A@&09A< KOWKL<#X&8,A!G;< CG;<1#4'9)F&$ 1=B8 !&,9><&,3QHIJ#A1*yB/G&!0 C3$*{'2!L<?
( ( ;
@&F/3&!
☐
1F
☐
1>4G;<R.&A@&0,!(10V5&#78WKL<#X&8/G;<1#4'9)F&$ 9='#&05#,&6<&8R`0(R`, CKQ<&,]&KC1F?
( `M
@&F/3&!
☐
1F
☐
1>4G;<R.&A,!(10V5&#78WKL<#X&8 CG;<1#4'9)F&$9='@&0!.&A1FV1_48C1F?
( (
@&F/3&!
☐
1F
☐
1>4G;<R.&A2>"?@&0YFL< 3&A(-.|0 C5&A(%L<C1F?
( L$
@&F/3&!
☐
1F
☐
1>4G;<R.&A2>"?@&01%A$K&0-&6,&6<&8 CK&<}!$= C<&,%2#&#KOD=%"1!;_& (^F&_,* #Q>2AL! #Q>2!) C1F?
( O S X X O
@&F/3&!
☐
1F
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 2?
. Z
< H ] N
.
]
<
]
.
Teen
(Self Report) – Identified
!
!
Cambodian)2020
Cambodian)2020
!"#$!%')*+,-/01',23)4579):);9!=' )>?'*$!%75*BC/9)D;')
(Pediatric ACEs and Relevant Life Events Screener) (P
EARLS)--,;> (Child)
&
( ( . (
&
6
8 <
( @
A
(
&
.
6
E F
G
H
ស"មាប់បំេពញេដោយអ/កេមើលែថទាំ
!"#$%&'()*+,'.- /0
'123/%$4 '5 !260 +,78- 9:"!;'<=>0;
'123/%$45?:!0 !"%*"!5*6@"4"(5AB">.D6'!260C
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='
!0R,;>4;Q ,#>R-R!4;)5R%!V>X# 4',;>!0R4; ,C-_,#>YL7#';,I ,Y#9)R\='/ P-B*YL,3")Q
,*9),'/b-#;,c# d0P>',;>!0R4;,;*-; ,*,;>!0R4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)[")
,;*,j>? R-!-0k/01',23)'4**$/ )>0L0_)Q !"#!$%&')& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A4
9:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GH631#.483$1KB/!$*+,F&$62!L610B/ % “@&F/3&!N”
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
H ]
.
T ^ ] T
W
^
W W .
H
E
]
. .
.
^ ^ < ` a
.
.
^
O E W .
H
E
]
. .
H
E
] N
E .
A
(
&
T
. .
T ^ l
T
(
&
. . (
l
<
]
(
IJ M
!"#$%& 1
§
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3+/E=$F'%?
/ A / A
§ '()0#$EG(@3 '$*+,-./0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
/ I >& /
§
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"LSG( 78LX$?S,X( 78LX-(<&,8=P8>+
LX$?S,X( 8>+LX-("2RLSG( PTSD F78LX-(QY:43,8)
/ A > I VW 2R > VW VW >G
>G > VW >G Z
§ '();<=$8>3:/0#$'8)?!@% 3A123-J-83@ '8)?+3: F-+[3-'$*+,-./0#$F'%?
/ /
§ '();<=$8>3:-'+\)(,-./'$*+0#$ F0#$'8)?!@% 3AH38*3$123- F-S]C-^5835-NO37389:$3,"_$.=,3 F'J-)@#3'M`5P=.S^3- F@#3'L7a-Na3'JS)5'<$F'% ?
/ / # A / A
§
'()'$*+,-./0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3< F8G5435%%9?
$3,!@%3 '56'<?f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
/ / I
A W /
§ '()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<MLY:H38#3$'"i+'%j(F'%? ឬ '()'$*+
,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL'E%c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
/ / /
/ b)
§ '()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $Nk$ %c$A'"2`+ F'4dc'4d$089:B3$/'$*+,- ./0#$F'%? ឬ '()835-=Eh?'<M
LY:H38#3$'56$#C+J$=8JE9.3,123-L3:'$*+,-./0#$P23A+'<$ B?/'1'0d:'$*+,-./0#$835 .23$.#38 FJ(KL,-9.F'%? ឬ '()835-=Eh?'< MLY:H38#3$
'56$#C+J$=8JE9.3,123-EJ838'$*+,-./0#$ FJ-J<_(B3$ !B?435'1'0d: '$*+,-./0#$P23S@3 <9$'E03SJ(KL435'143-F'%?
/ / / b&
/ / b) /
/ > / b) b)
§ '()'$*+,-./0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$435-mc'$*+,-./0#$ F. '0 d:'$*+,-./0#$-mc-=E?'5dc (38,'-j-
!B?<S+/435 F'1'0d: '$*+,-./0#$83503,8*H8G5J.9? F0#$H38#3$123--m=5-m+ F123-435,98'Q%(3883(/ (38,5nEK@ F(38,5n':d5 7389:'$*+
,-./0#$F'%?
/ I / =A h
=A b) I / / / &
§ '()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$%A5+,- ./0#$'8)?!@%3A,-./'$*+0#$F'%? T%3U,H ;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 F
oBEK'.#U3435',)SK?8$'56 F',)'SM'%6F'%?
/ / =A / I
0;L,-# “"1/dR” V>X# R?90Bm;1-#n
T N
. W E
]
.
^
R-0
),U9>,1p* R?90R%!BC/,i R/Q
T A o
E W
^
E
Child (Parent/Caregiver Report) – Deidentified!
!
!"#$%& 2
.K8EK. "43%/S3." !B? J(KL5_+.AHp,q
§ '()'$*+,-./0#$123-'D)M ? F123-730#$,+'JEdco50A'<UG+i3'56$#C+QK8r35 .UE85 F.3?3,-./0#$F'%? (T%3U,HIJ(KL435
'E.82C('143- -A<35 F.$8*Q3<UG+i3'"i+s'%j( .t+h38 FQ3,L$8*)
/ W / ) G I
b)
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HJ(KL435'E,lP35 F'1'0d: 83503,8*H03-/'0d5 F8G5,3-/-N]R? 'Bd:
.3,!(<K708^R, 73(G.3.5 0(>.Nu3H'Q% %A'5d,"2RL'Q% .3.53 Q 3< P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I I b) I
I
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"vc'56 $3,8G5835$!52+rG('@,'B)8^.#3$/'56 435',)
$!52+'JS)573+<&,B+'56$#C+,:w'<?J43A89:!P 435J-f88=P5_+$3,-'HxM'SM F$3,,y-0K. FJ(KL!(,. /'567389:J$=8
JE9.3,73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I &
/
43%/S3.
☐
'%
☐
§ '()0#$123-43,8Z@3 '$*+,-./0#$8G58358OR-JE-/JE35 'B)8^MC3 F@38OR-.J83-/'$*+,-./0#$5_+0./8=5'<?0#$03S%GM!@8
'%j(?
/ / & A
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$123-435!-$<&;<=$8>3: F0#$'8)?!@%3A 'Bd:.3,!($3,SGN]_8-'Hxdc03.5 FSAHz?J.=$?
/ #
43%/S3.
☐
'%
☐
§ '()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+ $3:1V5/1V, F<G$3,Q3<?
/ VW
43%/S3.
☐
'%
☐
§
'()$K5,-./0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'%?
/ /
43%/S3.
☐
'%
☐
0;L,-# “"1/dR” R?90Bm;1'!n
T N
. E
]
. .
Child (Parent/Caregiver Report) – Identified
Cambodian)2020
Cambodian)2020
!"#$!%')*+,-/01',23)4579):);9!=' )>?'*$!%75*BC/9)D;')
(Pediatric ACEs and Relevant Life Events Screener)
(PEARLS)--!"#$!%H?904;,-/BJK,;>
(Te
en Caregiver Report)
&
( ( . (
&
6
8 <
( @
A
(
&
.
6
E F
G
&
E
I
. L
M
ស"មាប់បំេពញេដោយអ/កេមើលែថទាំ
!"#$%&'()*+,'.- /0
'123/%$4 '!5 62 0 +,78- 9:"!;'<=>0 ;
'123/%$4 ?5 :!0 !"%*"!5*6@"4"(5AB">.D6'!602C
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01 ',23)V>X# YL0[D/R\=' )>R\9/='
!0R,;>4;Q ,#>R-R!4;)5R%!V>X# 4',;>!0R4; ,C-_,#>YL7#';,I ,Y#9)R\='/ P-B*YL,3")Q
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
H ]
.
T ^ ] T
W
^
W W .
H
E
]
. .
.
^ ^ < ` a
.
,
*9),'/b-#;,c# d0P>',;>!0R4;,;*-; ,*,;>!0R4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)[")
,;*,
j>? R-!-0k/01',23)'4**$/ )>0L0_)Q !"#!$%&'()& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8 “C” 1A4
9:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GHIJ631#.483$1KB/!$*+,F&$62!L610B/% “@&F/3&!N”
.
^
O E W .
H
E
]
. .
H
E
] N
E .
A
(
&
T
. .
T ^ l
T
(
&
. . (
l
<
]
M
!"#$%& 1
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?123-435'56$#C+$!52+D=AD3A+/E=$F'%?
'()0#$EG(@3 '$*+,-./0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"2RLSG( 78LX$?S,X( 78LX-(<&,8=P8>+LX$?S,X(
8>+LX-("2RLSG( PTSD F78LX-(QY:43,8)
'();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-'$*+,-./0#$F'%?
'();<=$8>3:-'+\)(,-./'$*+0#$ F0#$'8)?!@%3AH38*3$123- F-S-^5#835-NO37389:$3,"_$.=,3 F'J-)@#3'M `5P=.S^3- F@#3'L7a-Na3'JS)5'<$F'%?
'()'$*+,-./0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3< F8G5435%%9?$3,!@%3
'56'<?f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
'()'$*+,-./0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@% 3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<MLY:H38#3$'"i+'%j(F'%? ឬ '()'$*+,-./0#$
123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL'E %c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $N$ %c$A'"2`+ F'4dc'4d$089:B3$/'$*+,-./0#$F'%? ឬ '()835-=Eh?'<MLY:
H38#3$'56$#C+J$=8JE9.3,123-L3:'$*+,-./0#$P23A+'<$ B?/'1'0d:'$*+,-./0#$835 .23$.#38 FJ(KL,-9.F'%? ឬ '()835-=Eh?'< MLY:H38#3$'56$#C+J$=8
JE9.3,123-EJ838'$*+,-./0#$ FJ-J<_(B3$ !B?435'1'0d:'$*+,-./0#$P23S@3 <9$'E03SJ(KL435'143-F'% ?
'()'$*+,-./0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$/435-mc'$*+,-./0#$ F. '0d:'$*+,- ./0#$-mc-=Eh?'5dc (38,'-j- !B?<S+/
435 F'1'0d:'$*+,-./0#$83503,8*H8G5J.9? F0#$H38#3$123--m=5-m+ F123-435,98'Q%(3883(/ (38,5nEK@ F(38,5n':d5 7389:'$*+,-. /0#$F'%?
'()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$/%A5+,-./0#$'8)?!@%3A,-./'$*+0#$F'%? T%3U,H ;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 FoBEK
'.#U3435',)SK?8$'56 F',)'SM'%6F'%?
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 1?
. Z
< H ] N
.
]
<
]
.
R-0
),U9>,1p* R?90R%!BC/,i R/Q
T A o
E W
^
E
Teen (Parent/Caregiver Report) – Deidentified
!
9:;<FO 2
!"#%"! "@&F/3&!" 9='2>"?0J6!$*+,N
'()'$*+,-./0#$123-'D)M ? F123-730#$,+'JE dco50A'<UG+i3'56$#C+QK8r35 .UE85 F.3?3,-./0#$F'%? (T%3U,HIJ(KL435'E
.82C('143- -A<35 F.$8*Q3<UG+i3'"i+s'%j( .t+h38 FQ3,L$8)
/ W / ) G I
b) *
43%/S3.
☐
'%
☐
'()'$*+,-./0#$835-%<G'.d155KL$3,',).'0)+ (T%3U,HJ(KL435'E,lP35 F'1'0d:83503,8*H03-/'0d5 F8G5,3-/-N? 'Bd:.3,
!(<K708^R, 73(G.3.5 0(>.Nu3H'Q% %A'5d,"L'Q% .3.53 Q 3< P=.E#3o5 $3,',j5.KJ( F<G$3,Q3<) F'%?
I I b) I ]R
I 2R
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-835-NO3 7389:$3,.#3$'56 (T%3U,H $3,8G5835"vc'56 $3,8G5835$!52+rG('@,'B)8^&.#3$/'56 435',)
$!52+'JS)573+<&,B+'56$#C+,:w'<?J43A89:!P 435J-f88=P5_+$3,-'HxM'SM F$3,,y-0K. FJ(KL!(,./'567389:J$=8JE9.3,
73'JS)5 F.837G$JE9.3,73'JS)553$) F'%?
/ / I
/
43%/S3.
☐
'%
☐
'()0#$123-43,8Z@3 '$*+,-. /0#$8G58358OR-JE-/JE35 'B)8^MC3 F@38OR-.J83-/'$*+,-. /0#$5_+0./8=5'<?0#$03S%GM!@8 '%j(?
/ / & A
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-435!-$<&;<=$8>3: F0#$'8)?!@%3A 'Bd:.3,!($3,SGN]_8-'Hxdc03.5 FSAHz?J.=$?
/ #
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?83578,3+ $3:1V5/1V, F<G$3,Q3<?
/ VW
43%/S3.
☐
'%
☐
'()$K5,-./0#$123-,./'567389:;<=$8>3: F0#$'8)?!@%3A!B?435.23-'%6'U):F'% ?
/ /
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-/J(KL435D%=$ S3-P2{5 F73-/E=$F'%?
=A /
43%/S3.
☐
'%
☐
'()'$*+,-./0#$123-/J(KL435'E-A<35P3+,3+$3: F<3$|.AB F$3,EJ838< oBEK'.#U3 (T%3U,H 8G(J-=. 8G(J.) F'%?
& & I > > &
43%/S3.
☐
'%
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 2?
. Z
< H ] N
.
]
<
]
.
Teen
(Parent/Caregiver Report) – Identified
!
Cambodian)2020
Cambodian)2020
"#$%"&(*+,-.012(-34*568:*;*<:">( *?@(+%"&86+CD0:*E<(*
(Pediatric ACEs and Relevant Life Events Screener)
(PEARLS)---<? ("#$%"&J@:1K*N?)
(Teen (Self Report))
'
) ) / )
'
7
9 =
) A
B
)
'
/
7
F G
H
I
'
F
L
M
ស"មាប់បំេពញេដោយអ/កជម7ឺ
កាលបរិេចទៃថេន- ះ៖) ៃថែខ- ឆ:ាកំេ ណើត៖ំ
េឈ2ោះរបស អ់ :ក៖
?I2!K,?L)")M>$*?'*$!%CP)*>Q 4R!#S,'/#!,U 01',23)V>X# YL0[D/R\=' )>R\9/='!0R
4;Q ,#>R-R!4;)5R%!V>X#4';)!0R4; ,C-_,#>YL7#4; ,Y#9)R\='/ P-B*YL,3")Q
J
.
N
E @
A
(
&
O
@ E
T
(
&
W Z E
<
(
< <
E
]
.
T ^ ] T
W
^
W W .
T
E
]
. .
.
^ ] < ` a
.
,
*9),'/b-#;,c# d0P>'4;,;*-; ,*4;e0,fg h9)5*9) ,i,'/01',23)CL*,U,)["),;*
,j>? !
"#,7#AHIP'AFKQ1!BR0KOG>O><&' 0Q6A3ITAU0;N !"#!$%&'()& !$*+,-./#&0123405&6#789:;< 9='2>"?@&09A693<1=B8
“C” 1A49:;<*&#78D0!$*+,2>"?@&01E.48)& “@&F/3&!” GHIJ631#83$1KB/!$*+,F&$62!L6% “@&F/3&!N”
.
^
O E W .
]
. .
] N
E .
A
(
&
T
.
.
S
.4 M
9:;<FO 1
'()0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3A !B?123-435'56$#C+$!52+D=AD3A+/E=$F'%?
/ /
'()0#$123-83503,8*H@3 8G5J(KL435E3AJ% 8G5435%%9?$J.?3M 5G+/F8G5J(KL435$3,<3,F'%?
/ I >& /
'()0#$123-435,./'567389:;<=$8>3:/0#$'8)?!@%3 !B?835-NO3.=PQ3<"2RLSG(? (T%3U,H 78LX-(>G"2RLSG( 78LX$?S,X( 78LX-(<&,8=P8>+LX$?S,X( 8>+LX-("2RL
SG( PTSD F78LX-(QY:43,8)
/ A > I VW > VW VW >G >G
> VW >G Z
'();<=$8>3:/0#$'8)?!@%3A123-J-83@ '8)?+3: F-+[3-0#$F'%?
/ /
'();<=$8>3:-'+\)(,-./0#$ F0#$'8)?!@% 3AH38*3$123- F-S]C-^5835-NO37389:$3,"_$.=,3 F'J-)@#3'M`5P=.S^3- F'J-)@#3'L7a-Na3'JS)5'<$F'%?
/ / # A / A
'()0#$123-PbcP3($3,!@%3A.8J.- 'Bd:0#$'8)?!@%3AH38#3$ (T%3U,H 8G5J(KL435$3,<3,<&.e35Q3<!B?8G5835.=L(eGQ3< F8G5435%%9?$3,!@%3 '56'<?
f F835,-9. '%dc73'<?'5dc83515135">?7K5$g'Bd:)?
/ / I A
W /
'()0#$123-'D)M F?W;<=$8>3:/0#$'8)?!@%3AJ(KL435'E!J.$B3$ '7 J-83@ '8)?+3:'Bd:-=Eh?'<M LY:H38#3$'"i+'%j(F'%? ! '()0#$123-'D)M F?W;<=$
8>3:/0#$'8)?!@%3AJ(KL'E%c$A'"2`+ %3(/ B3?/ FL3: F'143-'Bd:03L=1F'%?
/ / / /
b)
'()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123- F73M_$M3-/435,=M $Nk$ %c$A'"2`+ F'4dc '4d$089:B3$/0#$F'%? ! '()835-=Eh?'<MLY:H38#3$'56$#C+
J$=8JE9.3,123-L3:0#$P23A+'<$ B?/'1'0d:0#$835.23$.#38 FJ(KL,-9.F'%? ! '()835-=Eh?'<MLY:H38#3$'56$#C+J$=8JE9.3,123-435EJ838$A!U+0#$ F435
J-J<_(>B3$ !B?435'1'0d:0#$P23S@3 'E03S'143-0#$F'%?
/ / / b& /
/ b) / /
/ b) b)
'()0#$123-J(KL435'E,l'?dQ-A<35P3+"2RL'Q%F'%? T%3U,H 0#$H38#3$435-mc0#$ F.'0d:0#$-mc-=Eh?'5dc (38,'- j-!B?<S+/435 F'1'0d:0#$835
03,8*H8G5J.9? F0#$H38#3$123--5-m+ F123-435,98'Q%(3883(/ (38,5nEK@ F(38,5n':d5 7389:0#$F'%?
/ I / =A =A b)
I / / m= / &
'()123-835$3,"23.->R,1AB '56$#C+.e35Q3<%A53$%A5+,-. /0#$'8)?!@%3A,-./0#$F'%? T%3U,H ;<=$8>3:/0#$'8)?!@%3A435!?+?c F!-$E#3 FoBEK'.#U3435
',)SK?8$'56 F',)'SM'%6F'%?
/ / =A / I
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 1?
. Z
< H ] N
.
]
<
]
.
R-0
),U9>,1p* R?90R%!BC/,i R/Q
T A o
E W
^
E
Teen (Self Report) – Deidentified
!
9:;<FO 2
!"#%"! "@&F/3&!" 9='2>"?0J6!$*+,N
1>4G;<R.&A1V4W ' CR.&A5&G;<,612%B/D0G$1KXQ6Y&10Z<;T6["#\&0 !X%#0 C!&'&,A!(G;<C1F ? (]F&X,*S2>"?
@&01%!#.T>1R@&A A$K&0 C!<#_[&KXQ6Y&1:Y6`1Fa> !b6c&# C[&,?<#)
( M ( 4 Q S
^4 _
@&F/3&!
☐
1F
☐
1>4G;<#&0AFKQ1!BR00"?<&,1,4!1G46 (]F&X,*2>"?@&01%,d-&0 C1R1GB8#&0G&,#_*G&A(1GB0 C#Q0,&A(AHIP' 1=B8
!&,9>K"5G#UP, 5&>Q!&!0 G>e!Hf&*1[F F$10B,:.P?1[F !&!0& [&K-L!%;&D0<&,1,a0!"2> CKQ<&,[&K) C1F?
S S ^4 S
S
@&F/3&!
☐
1F
☐
1>4G;<R.&A#&0AHg& 5&#78<&,!;&<10Z (]F&X,* <&,#Q0#&0:h/10Z <&,#Q0#&0<90.6\Q>1),1=4#U!;&<(10Z @&01,4
<90.612305&6KO,=610Z<;T6,8i1K'2@&$#789- @&02A j##L-0J6<&,A1*kW13W C<&,,lAG"! C2>"?9>,!(10Z5&#78
2<L#2%7!&,5&12340 C!#&5Q<2%7!&,5&123400&<) C1F?
( ( S O
4
(
@&F/3&!
☐
1F
☐
1>4G;<R.&A@&,#m)& G;<#Q0#&0#gPA2% A(2%&0(1=4#UOWT& C)&#gPA0J6G!(#L01K'G;< CnKL<#e&8/G;<1#4'9)F&$,A!(
G;<G&3FQW9)# 1Fa>?
( $
@&F/3&!
☐
1F
☐
1>4G;<R.&A@&09A< KOnKL<#e&8,A!G;< CG;<1#4'9)F&$ 1=B8 !&,9><&,3QHIJ#A1*kB/G&!0 C3$*o'2!L<?
( ( ;
@&F/3&!
☐
1F
☐
1>4G;<R.&A(@&0,!(10Z5&#78nKL<#e&8/G;<1#4'9)F &$ 9='#&05#,&6<&8Rp0(Rp, CKQ<&,[&KC1F ?
pM
@&F/3&!
☐
1F
☐
1>4G;<R.&A,!(10Z5&#78nKL<#e&8 CG;<1#4'9)F&$9='@&0!.&A1FZ1X48C1F?
( (
@&F/3&!
☐
1F
☐
1>4G;<R.&A(2>"?@&0VFL< 3&A(-0 C5&A(%L<C1F?
L$ .q
@&F/3&!
☐
1F
☐
1>4G;<R.&A2>"?@&01%A$K&0-&6,&6<&8 CK&<r!$= C<&,%2#&#KOD=%"1!;X& (]F&X,* #Q>2AL! #Q>2!) C1F?
( O S e e O
@&F/3&!
☐
1F
☐
,*9) ""1/dR" 0q) BC/4;"),M#,i;>Bm;1 2?
. Z
< H ] N
.
]
<
]
.
Teen (S
elf Report) – Identified
!
!
Cambodian)2020
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 6: W Z E . . T (ACEs Aware)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document