ࡱ> | @  Hbjbj ؝؝ >(p``Da$p[<h(YL(O+(;(;(;(;(;(;$=R@L;===L;<GGG="OG=OGG(Ef SyF_Aps+<0[<@u@Epp@S Q^GLBL;L;pp^TuDW1ppTuCHILDREN S FOSTER CAREDHS FC Worker Load #: FORMTEXT      PERMANENT WARD SERVICE PLANDHS FC Worker Name: FORMTEXT      Michigan Department of Human ServicesPOS Agency Name: FORMTEXT      POS Agency Worker Name: FORMTEXT      County of Referral: FORMTEXT      Court Jurisdiction: FORMTEXT      Court Docket #: FORMTEXT      Report Period:  FORMTEXT      to FORMTEXT       (maximum three months) Report Date:  FORMTEXT       The date the report is completedIDENTIFYING INFORMATIONChild(ren): (List separately) name, date of birth, case number, date entered care, current placement type (if relative care, name and address of relative; if institution, name and address of institution; if foster home, note foster home placement only), date entered current placement, and permanency planning goal. Specify if the child(ren) is Native American and tribal affiliation, if applicable.NameDate of BirthLog NumberCase NumberChild GenderChild RaceHeightWeightHair Color FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Eye ColorReligionDated Entered CareDate of Current PlacementCurrent Placement TypeAnticipated Next Placement FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN Date of Anticipated Next PlacementCurrent Legal StatusFederal Permanency Plan GoalMichigan Specific Goal Description FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN Child s Address (if not FH) FORMTEXT      Native American? FORMDROPDOWN If Yes, Tribal Affiliation FORMTEXT      I.LEGAL STATUS A.Court History Child(ren): (list separately) name, petition date, petition type, hearing date, hearing outcome, order date, order type, requirements of the court through its order.  MACROBUTTON [2] "Click Here and Type"  B.Next Court Date:  MACROBUTTON [2] "Click Here and Type"  II.REASONABLE EFFORTSNote:For children who may be Native American, see Services Manual Item 742, Active and Reasonable Efforts A.Efforts made by the Agency to place the child in a permanent placement in a timely manner.   MACROBUTTON [b2] "Click Here and Type"  B.If services were not provided, explain the reasons why services were not provided.   MACROBUTTON [b2] "Click Here and Type"  III.SOCIAL WORK CONTACTS List date, person(s) contacted, role/position and type of contact (telephone, in person, home visit, office visit, etc.) for each contact, attempted contact and scheduled, but unkept appointments. Provide a brief narrative statement of the specific reason for the contact. Limit the narrative to one sentence.   MACROBUTTON [b2] "Click Here and Type"  IV.PROGRESS SUMMARY A.Child Reassessment 1.Child Needs and Strengths and Current Status: Indicate, for each permanent ward; Address and explain each individual item scored as a strength or need on the Child Assessment of Needs and Strengths. Identify and describe the priority needs of the child for service. Identify the situational concerns, which cannot be identified in consecutive report periods. List and describe all other strengths of the child whether identified on the assessment or not.   MACROBUTTON [b2] "Click Here and Type"  2.Placement Information The current placement and any replacements during the reporting period. any change in the placement household during the review period. Include results of Central Registry and criminal record checks and assessment of investigation if applicable, if new adults are in the placement household. Child nameLiving ArrangementBegin DateEnd Date FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Reason for Replacement:  MACROBUTTON [b2] "Click Here and Type"  3.Child(ren) s Current Status Indicate for each child under court jurisdiction: Describe current status of child including: Significant events since the last assessment; Distinctive characteristics. Emotional and physical development. Hobbies, likes and dislikes, etc., Relationships with siblings, if applicable, Behavioral and past experiences,   MACROBUTTON [2] "Click Here and Type"  4.Education Information Educational including the current school, grade, and pass or fail.   MACROBUTTON [2] "Click Here and Type"  5.Medical and Dental Information Medical, dental and optical appointments and outcomes during report period.   MACROBUTTON [2] "Click Here and Type"  6.Placement Resources a.Sibling Placement If child(ren) has siblings who are not placed in the same placement, provide an explanation of the reasons for the split placement. Note: If sibling placement is split, second line supervisor approval is required. The Second Line Supervisor must sign the PWSP in the space designated at the end of the PWSP. If there are no siblings or if siblings are placed together, write N/A.  MACROBUTTON [b2] "Click Here and Type"  bSibling and Relative Visitation Provide a report on all visits between siblings, if in separate placements, or any relative visits. Include all visits with adult siblings, siblings not in care and potential placements in the relative network. Include observations on the quality of the visits. Include a discussion of any exceptions (missed appointments, changed appointments, suspensions of appointments and changes in supervision status) to the plan during the reporting period. If there are no siblings or planned relative visits, write N/A in the space below.  MACROBUTTON [b2] "Click Here and Type"  c.Best Interests of Current Placement Describe the foster parent / relative caregivers willingness and capacity to meet the specified needs of the child and, Why this current placement is in the childs best interest.   MACROBUTTON [b2] "Click Here and Type"  7.Residential Care If the youth is 10 years of age or over and is placed in a residential or institutional setting: Document whether Wraparound or Assisted Care efforts were made to prevent the residential placement. Identify the plan for services that will allow the youth to be placed in a less restrictive setting. OR If the youth is under age 10 and is placed in a residential or institutional setting. Document whether Wraparound or Assisted Care efforts were made to prevent the residential placement. Document that a screening for Fetal Alcohol Spectrum Disorder was completed. Identify the plan for services that will allow the youth to be placed in a less restrictive setting. If there were no services provided, explain why not. If the youth is not placed in a residential or institutional setting, write N/A in the space provided.   MACROBUTTON [b2] "Click Here and Type"  8.Permanent Wardship For each child list the permanency planning and Michigan.a.Describe the effort made to finalize the permanency plan.  MACROBUTTON [b2] "Click Here and Type"  b.Attitudes regarding termination of parental rights and adoption.  MACROBUTTON [b2] "Click Here and Type"  c.Preparation of child for adoption.  MACROBUTTON [b2] "Click Here and Type"  d.Possibility of adoption by relative network or foster parents.  MACROBUTTON [b2] "Click Here and Type"  e.Efforts made to place the child(ren) for adoption or within the relative network. Statement of the efforts made to place the child(ren) for adoption or within the relative network.  MACROBUTTON [b2] "Click Here and Type"  f.Compelling Reasons. Document the compelling reasons why it is not in the childs best interest to be placed for adoption or within the relative network.  MACROBUTTON [b2] "Click Here and Type"  B.Foster Parent/Relative Caregiver Input Attach written input from the foster parent(s)/relative/unrelated caregiver for the child(ren). If a written statement from the foster parent(s)/relative/unrelated caregiver is not available, summarize the foster parents feedback.   MACROBUTTON [b2] "Click Here and Type"  V.RECOMMENDATION Recommendations to Court, if applicable. For each child, indicate whether the child should remain in placement, under the supervision of the courts, as appropriate or as State Wards. Request any other orders from the court as appropriate.   MACROBUTTON [b2] "Click Here and Type"  Department of Human Services of MichiganPermanent Ward Treatment Plan and Service AgreementThis treatment plan is developed to assure that each child will receive safe and proper care and services by the following activities. Service Type Code:AD =Alcohol or Drug Abuse RehabilitationFR =Reunification ServicesIL =Independent Living ServicesOT =Other Program NeedsDC =Day CareFC =Family Counseling/Outreach CounselingJT =Job Training/Employment AssistancePS =Parenting Skills TrainingED =EducationHS =Homemaker Services or Parent AidesMH =Mental Health ServicesTH =Individual/Group TherapyDV =Domestic Violence ProgramMD =Medical ServiceWP=WraparoundA. SERVICE REFERRAL TABLE Using the codes above for member referred and service provider type, enter the information for all services below. To enter additional services for following reports, place the cursor in the FIRST FIELD of the row ABOVE where you want the new row and click the Insert Svc Ref Row button to insert services between rows as needed. To enter continued headings, click in the FIRST FIELD on the new page and click the ADD SVCREF HEADING button. To remove continued headings, click the REMOVE SVC REF HEADING.  Family Member Name Barriers/ Needs Addressed  Service Type Code  Service Provider Name  Mo/Yr Re- ferred  Mo/Yr Start Target Com- pletion Date (Mo/Yr) Service Status  Completed Services  Com- pletion Date (Mo/Yr)  FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMDROPDOWN  FORMTEXT       Permanent Ward Treatment Plan and Service Agreement (continued) B. Foster Parent / Relative Caregiver Activities and Discipline and Child Handling Techniques1. List each goal for foster parent/relative caregiver, specific action steps, time frame for achieving, and expected outcome. 2. Describe the discipline and child handling techniques to be used while the child is in placement. 3. Describe the plan of supervision for the child while in placement. 4. Describe the plan for acceptable activities such as baby sitting, routine household tasks, privileges etc. 5. Justify the tasks and/or additional expenses provided by the caregiver that justifies the Determination of Care Supplement. If the youth is age 14 or older, detail the independent living preparation activities the foster parent/relative caregiver will provide to assist the youth. (See CFF 722-6 Independent Living Preparation.)   MACROBUTTON [b2] "Click Here and Type"  C. Individual Child ActivitiesDescribe all activities to achieve the permanency planning goal. List for each child, the service goals and action steps, time frame for achieving, and expected outcome. Goals should address areas prioritized on Child Needs and Strengths Assessment and activities of daily living (if applicable). 1. Identify what the agency and the provider need to do to meet these specific needs. 2. Address sibling visitation, if siblings are split. When separated, the relationship between siblings, must be maintained by detailed plan of visits, phone calls and letters. 3. For each ward age 14 or older (including those wards who become 14 years of age during the report period), include a description of the programs and services which will assist the youth to prepare for transition to a state of functional independence or the ability to take care of oneself physically, socially, economically and psychologically. Identify where, how and by whom these services are to be provided. (See CFF 722-6 Independent Living Preparation.)   MACROBUTTON [b2] "Click Here and Type"  D. Foster Care Worker Activities1. Identify services to be provided to the child and to foster parents / relative caregiver by the foster care worker. State activities which support the services offered. 2. State proposed foster care worker contact with the family, child, caretakers, and service provider, if applicable. 3. If the youth is age 14 or older, detail the independent living preparation activities that the worker will provide to assist the youth. (See CFF 722-6 Independent Living Preparation.)   MACROBUTTON [b2] "Click Here and Type"  The development of this plan was negotiated with: (also list those individuals who were unavailable to participate in the development and why not). Youth age 14 and older must be involved in the development of the plan and be responsible for its implementation with the assistance of identified individuals. Upon clicking in the Name and Title field below, a question box allows addition of a signature line for Youth Age 14 and Older, if applicable and/or additional Other Agency Worker Name rows.  MACROBUTTON [b2] "Click Here and Type"  CLICK HERE TO ADD YOUTH SIGNATURE FOR YOUTH AGE 14 AND OLDER  FORMTEXT    Name and Title:  FORMTEXT       Signature: Date:  FORMTEXT       DHS Local Office Name:  FORMTEXT      ,.Z\prt~  Z | ~ ۾۷ה۾۷wshww]whlhg"OJQJj\hg"Uhg"jhg"Uhlhg"5CJOJQJ hlhg"jhacUhlhg"5 hg"5hlhacOJQJ hlhacjhFUmHnHujhacUhacjhacUhlhac5CJOJQJhlhacCJ hacCJ$.Z  j}! j /$Ifgdac]kd$$IflF*l +    4 la $Ifgdac $Ifgdac 2$Ifgdac5 H  Z | ! j $Ifgdac $Ifgdac /$Ifgdp]kd$$IflF*l +    4 la ! j $Ifgdac $Ifgdac /$Ifgdac]kd $$IflF*l +    4 la   * , . B D F P R T V X ~   Ծԙɾəԙԙ|v h~CJ h~5CJj hLUjhLUhlhg"5OJQJjNhLUhlhg"5CJOJQJhg"5CJOJQJhlhg"OJQJ hlhg"jhFUmHnHujhg"Ujhg"Uhg"-   , T ! j $Ifgdac $Ifgdac /$Ifgdac]kd$$IflF*l +    4 laT V X v: j1]kdQ$$IflF*l +    4 la $Ifgdac $Ifgdac]kd$$IflF*l +    4 la v: jv: j'!]kd $$IflF*l +    4 la $Ifgdac $Ifgdac  F L  $Ifgd~ $Ifgd~]kdc $$IflF*l +    4 la 4 6 8 B D F J L N b d f p r v   ͖|o|_|Qh~<B*OJQJphjhFCJUmHnHuj h~CJUjh~CJU h~CJh~CJOJQJh~5CJOJQJh~<B*CJOJQJph!h~5<B*CJOJQJphj h~U h~CJ h~5CJjhFUmHnHuj h~Uh~jh~U  jjwh#|wdL$Ifgd~ $Ifgd~pkdR $$Ifl\0?*Q]+4 la      0*v:sj0*!09kd;$$Ifl*++4 la $Ifgdac7kd $$Ifl*++4 la $Ifgd~Jkd $$Ifl0\*@$+4 la     3 6 B C r s  ʾ~p~pc~pQcAcAch4+hG5>*CJOJQJ"h4+hG5>*@CJOJQJhG5>*CJOJQJhlhG>*CJOJQJhlhG5>*CJOJQJhac<B*CJOJQJph$hlhac<B*CJOJQJphhlhacCJOJQJhlhac5OJQJhg"OJQJhg"5OJQJhlhg"5OJQJ hlhg"h~OJQJh~CJOJQJ 4 5 6 B C v:Bv:Rv:RjKJkd$$Ifl0)**%+4 la $$Ifa$gdac $IfgdacMkd$$Ifl40*+4 laf4$If "0F^`^W^^^`^^^$pp$If]p^pa$gdo$pp$If]p^pa$gd v ".0DFHJ^`blnpr &ɾͶͯɍͶͯwjhGUjchGUjh5oUjhGUhGjhGU hlhGjhFUjOh5oUh5ojh5oUhlhG>*CJOJQJhG5>*CJOJQJh4+hG5>*CJOJQJ+FHp-$$$ ?$Ifgd vkdL$$Ifl F~ az 3%)8/d8+$$$$4 la8` ?$Ifgdo ?$Ifgd v&(*468:NPR\^`bvxz46bdٸݦvvvvv&h4+ho5>*CJOJQJ^JaJ ho5>*CJOJQJ^JaJ hlhoho#hlhGCJOJQJmHnHujhGUj;hGUjhGUhG hlhGjhFUjhGUjOhGU(/&|) ?$Ifgd vkd'$$Ifl F~ az 3%)8/d8+$$$$4 la6dR^b^j^ ^ ^$$If]^a$gd v $$Ifa$gd v9kd $$Ifl)T*+4 la*,.8:<>Z\^`b~ʼujjhFUj7h[=Ujh[=Ujh[=U hlh[=jhFUjmh[=Uh[=jh[=Uhlho>*CJOJQJ&h4+ho5>*CJOJQJ^JaJ ho5>*CJOJQJ^JaJ h~5>*CJOJQJ^JaJ'<`G>>>>> ?$Ifgd vkdm$$Ifl ֈ 6x)*:>Bz  +4 lap<~24xz|~dzdzdzǟ원}rg؛j]!hFUjhFUj[h[=UjhFUjh[=Uh[=&h4+h[=5>*CJOJQJ^JaJ&hh[=5>*CJOJQJ^JaJ h[=5>*CJOJQJ^JaJhlh[=CJOJQJ hlh[=jh[=Uj;hFU(`@7|) ?$Ifgd vkd$$Iflֈ 6x)*:>Bz  +4 lap< ?$Ifgd[=4zR^b^n ^ $$Ifa$gd v$$If]^a$gd v@kd$$Ifl)T*+4 lap z|wnnnn ?$Ifgd vkd%$$Ifl\ )*:F+4 lap(Ryp|)6( $<$Ifa$gd v9kd/$$$Ifl)T*+4 la ?$Ifgd vkdy#$$Ifl\ )*:F+4 lap(RThjlvx"$&(*.0HJLNVpr{wowjhrUhr hr5h[=OJQJh[=<B*phh )Ih[=5h[=CJOJQJh[=5CJOJQJ h[=5CJjY'hlh[=Uj%hFUjhlh[=UjhFUj|$h[=Uh[=jh[=U hlh[=(Rz|   $Ifgd vJkd.%$$Ifl0 )Y +4 la ?$Ifgd v "$^P|)$If]^kdw($$Ifl\6 )" (+4 lap($&(*0JL|)jzj&j&j$If:kd)$$Ifl4)T*+4 laf4 $$Ifa$:kdc)$$Ifl4)T*+4 laf4LNPVjj5]kdt*$$IflFB)$+    4 la $Ifgdr $$Ifa$gdr $IfgdrMkd*$$Ifl40B)'+4 laf4  #$%j3jjbpkd*$$Ifl\U * 4 la $$Ifa$gdr $IfgdrgdrF^FgdrF^Fgdr    #')*;PQRTUZ[rstCDEFXmnoqȽȽȽȡ~rh 1<B*CJphh 1CJOJQJ h 15h 1B*phh 1jh 1Uh 15CJOJQJ!ho5<B*CJOJQJphho5CJOJQJhoCJOJQJhohrCJOJQJhr5CJOJQJjhrUhrhrB*ph+%&'()STUVWXYZ*j| $IfgdrF^Fgdr7kdk+$$Ifl**4 la $$Ifa$gdr Z[_r{ujly'j $$Ifa$$Ifkd+$$Iflr 4$* T _*4 larstzjJj`kd,$$Ifl4FB*%*    4 laf4$IfMkdZ,$$Ifl40B*Q(*4 laf4BCDEpqrsvj$j$jj$j$j$If8^8`kd:-$$Ifl4FB*%*    4 laf4 $$Ifa$ 'jFHkd5.$$Ifl40:x)y(4 laf4$If$If8^8[kd-$$Ifl4F>|)%    4 laf4QRST'{{yss s $Ifh^h^Hkd.$$Ifl40: x)n(4 laf4 d8$IfZd8$If^Z` d$If $d8$Ifa$ QRSTUg|}~ #c޾޾޾޾sb޾!h;M5<B*CJOJQJph!hD5<B*CJOJQJph!hJ 5<B*CJOJQJph!h 15<B*CJOJQJphh 15>*CJOJQJhD5CJOJQJh 15CJOJQJh 1B*phjh 1U h 15h 1CJOJQJh 1hr<B*phh 1<B*ph&gj'j'j>jHkd/$$Ifl40>|)y(4 laf4$Ifkkd /$$Ifl\>=|)?4 la$If  j$j$jjjj!jp$ & F @$If^a$gdJ $$Ifa$gdJ $$Ifa$[kd0$$Ifl4F>|)%    4 laf4$If #!jTRLLR^nkdu0$$Ifl4\>|)"4 laf4 $$Ifa$gdg"$ & F @$If^a$gd;M$ & F @$If^a$gdJ   '(0156@A  ɸڮzj[jhF5UmHnHuj2h:h:5U h:5jh:5U'hLXhJ 5>*B*CJOJQJph!hJ 5>*B*CJOJQJphhJ CJOJQJ!h 15<B*CJOJQJph!hJ 5<B*CJOJQJphh 1CJOJQJh 15CJOJQJ h 15jh 1Uh 1 jj"j"j|jjjee$ & F h^$If^^a$gdJ skd0$$Ifl4\>|)"4 laf4 $$Ifa$$If  (h_j_jSjS jSjS"j $$Ifa$gdH $IfgdHskdw1$$Ifl4\>|)"4 laf4 $$Ifa$gdJ $ & F h^$If^^a$gdJ (12345jG>j>jj5 $IfgdH $IfgdHkd1$$Ifl֞Dd#|) ~ V4 la $$Ifa$gdH $&(2468LNPZ\^`tvxɼɼ{si^iZRjhrakUhrakh|j5CJOJQJh|jCJOJQJhOJQJhLXh5 h5hCJOJQJhJ CJOJQJj4hLXhJ 5Uj3hLXhJ 5UjhLXhJ 5UjhF5UmHnHujH3hHhH5U hH5jhH5UhLXhJ 5 6^JAjAj $IfgdHkd4$$Ifl֞Dd#|) ~ V4 la $IfgdHj ">kdS5$$Ifl֞Dd#|) ~ V4 la $IfgdH $$Ifa$gdH*,.jjj"j"jviigg   @ ^ gdrakskd 6$$Ifl4\>|)"4 laf4 $$Ifa$gd|j $Ifgd|j $&(*,.268rF a c !"!#!$!'!)!+!,!B!C!W!k!l!r!!!!!ͼ⧟͇vevev!hD5<B*CJOJQJph!hp5<B*CJOJQJphhg"hg"5CJOJQJaJhg"B*phjhg"Uhg"!h75<B*CJOJQJph!hg"5<B*CJOJQJphhg"5CJOJQJhrakCJOJQJhg"CJOJQJjhrakUhrakB*phhrak'.028pr F c jj"j"jz$ & F3$Ifa$gd7$ & F2$Ifa$gdg"$ & F1$Ifa$gdg"$ & F0$Ifa$gdg"$ & F/ @$Ifa$gdg"$ @$Ifa$gdg" $$Ifa$gdg" $$Ifa$gdp $Ifgdp %!&!'!(!)!,!"j|ssjjjaajaj $Ifgdp~ ^~ gdg"F^Fgdg"rkd6$$Ifl\D*"4 la$n$If^na$gdp ,!B!C!!!!!!!!"j"j"jd[[RR~ ^~ gdg"F^Fgdg"rkd 7$$Ifl\D*"4 la$ & F3$Ifa$gdg" $$Ifa$gdg" $$Ifa$gdp !!!!!!!!!!!!!'")"+","="R"S"T"U"V"W"Y"Z"["\"p"t""$ $ $ $$̻wwfbZbjh 1Uh 1!h 15<B*CJOJQJphh 15CJOJQJhph 15CJOJQJhphp5CJOJQJhFq5CJOJQJh 1CJOJQJh7hv!hp5<B*CJOJQJphhp5CJOJQJhg"5CJOJQJhg"CJOJQJhg"B*phjhg"Uhg"#!!!!!!!'"(")"jj"j"j"j^rkd7$$Ifl\D*"4 la$ & F0$Ifa$gdp $$Ifa$gdp $Ifgdp~ ^~ gdg" )"*"+"U"V"W"X"Y"\"p"q"r"s"j"j"jjjskd7$$Ifl4\>|)"4 laf4 $$Ifa$$If~ ^~ gdg"F^Fgdg" s"t"u"x""##$ $ $jjjjXR~ ^~ kdm8$$Ifl4r>$ |)X 4 laf4$ & F $If^a$ $$Ifa$$If $2$3$4$5$6$9$H$P$\$$$%%%A&I&p&q&r&s&&&&&&&&&&&'''''''''''''''R(S(s(~(w)x))))ѵѵܙѵ!h?M5<B*CJOJQJphhFq5CJOJQJ!hQD\5<B*CJOJQJph!h 15<B*CJOJQJphhQD\5CJOJQJh 15CJOJQJh 1CJOJQJ h 15jh 1Uh 1h 1B*ph5 $5$6$7$8$9$:$<$\$$/%b%&p&jjjj$ & F!$If^a$ $$Ifa$$If~ ^~ p&q&r&&&&&&&&&}wwwuoojfjfjfj $$Ifa$$If~ ^~ kd8$$Ifl4r>$ |)X 4 laf4 &B'~''''''''c]]][U$If~ ^~ kd9$$Ifl4r>$ |)X 4 laf4 $$Ifa$$ & F"$If^a$ ''''%((((((J))a*****j"j"j$ & F#$If^a$$ & F#$If^a$ $$Ifa$$If))*++++)+*+++,+-+0+1+G+H+K++++++++++++++++<,=,>,?,Q,f,g,h,i,j,k,n,,ϿϺӯӚϿϺӋϿϺ}rh;M5CJOJQJh;MCJOJQJhrakhD5CJOJQJhDhDCJOJQJh 15CJOJQJhFq5CJOJQJ h 15h 1B*phjh 1Uh 1h 1CJOJQJ!h 15<B*CJOJQJph!h?M5<B*CJOJQJph,*++,+-+.+/+0+3+F+G+}}jtt"jt"j $$Ifa$$If^skd:$$Ifl4\>|)"4 laf4 G+H+I+J+K++jjvjk"| "$IfgdD $$Ifa$gdD $IfgdDskd:$$Ifl4\>|)"4 laf4+++++++jjvjvjmR| $IfgdD $$Ifa$gdD $IfgdDskd;$$Ifl4\>|)"4 laf4++++++++++xooic]]jTjTj $$Ifa$$If^^ ^ gd;Mkd;$$Ifl4r>R |)* 4 laf4 +<,=,>,i,j,k,l,m,n,q,Rjtnnnlffjjj$If~ ^~ kd<$$Ifl4r>R |)* 4 laf4 $$Ifa$ q,,,,,,,,,,ujlfffd^^jUj $$Ifa$$If~ ^~ kd<$$Ifl4r>R )M 4 laf4 $$Ifa$gd;M ,,,,,,,,,,,,- - - --2-3-4-5-6-:-;-}-~---------..... .$.%.;.......ӽzӽz!hQD\5<B*CJOJQJph!h 15<B*CJOJQJphhQD\5CJOJQJh?M5CJOJQJh 15CJOJQJhD5CJOJQJh;M5CJOJQJh 1CJOJQJ h 15h 1B*phjh 1Uh 1h;MCJOJQJ0,,- - -5-6-7-8-9-jRjc]]][UUj$If~ ^~ kd=$$Ifl4r>R |)* 4 laf4 $$Ifa$gd;M $$Ifa$ 9-:-=-----. .!.".jjRjoicc]W$If ^  ^  ^ kd=$$Ifl4r>R |)* 4 laf4 $$Ifa$ ".#.$.'.;........jjjRjnlff` ^  ^ kd>$$Ifl4r>R |)* 4 laf4 $$Ifa$$If ......./ ///I/Q/[////00000/00010203040G0I0r0;1=1>1P1e1f1g1h1i1k1m111ܹч~uh 15OJQJhQD\5OJQJ!h 15<B*CJOJQJph h 15CJhp5<B*CJphhQD\5<B*CJphh 15<B*CJphhQD\5CJOJQJh 15CJOJQJh 1CJOJQJ h 15jh 1Uh 1h 1B*ph+../|/000020304070F0G0j$j$'j'j8^8[kd>$$Ifl4F>|)%    4 laf4%$If $$Ifa$ G0H0I0r01:1;1<1=1j'jMKHkdy?$$Ifl40>|)y(4 laf4$ & F$$If^a$ $$Ifa$$IfHkd?$$Ifl40>|)y(4 laf4=1h1i1j1k1l1m111111v:!v:m v:a v:v:pkd?$$Ifl\ b,:WW\E O94 la  $$Ifa$ $$Ifa$$If$If$^a$h^h 111111111111111a2b2c2d2v2x22213333333'454P4R4S44Y5l5N6O6P677;7<7F7ʰ􎇎{hVm]jhVm]U hVm]5@ hVm]5h 1<B*CJph h 15;<B*OJQJphh 15<B*OJQJphh 15CJOJQJh 15CJOJQJh 1mH nH u h 16h 1OJQJh 15OJQJh 1h 1OJQJ,1111111[ v:v:#1,!i v: %d$If$If]kde@$$IflFh,:h3 O9    4 la $If111111v:#1,!i v:$If$Ifskd@$$Ifl4\ ,.:W$A O94 la f411`2a2b2c2w8|w8|MDw8 ?$$Ifa$7kd B$$Ifl:O9O94 la $IfskduA$$Ifl4\ ,.:W$A O94 la f4c2d2w2x2}222222w8jujjRj jjAj $If]<kdB$$Ifl4$:O9O94 la f4$If<kdYB$$Ifl4$:O9O94 la f4 222223 323c]j]j]Rj] j]j]Aj$Ifkd C$$Ifl4$ֈVf!$:* O94 la f4233393\3a3{333c]j]j]Rj] j]j]Aj$IfkdC$$Ifl4$ֈVf!$:* O94 la f433333333c]j]j]Rj] j]j]Aj$IfkdD$$Ifl4$ֈVf!$:* O94 la f433344#4'424c]j]j]Rj] j]j]Av:$Ifkd[E$$Ifl4$ֈVf!$:* O94 la f424344454c]w8v:":kdF$$Ifl4:O9O94 la f4$Ifkd!F$$Ifl4$ֈVf!$:* O94 la f454Q4R4S44:556N6O6P6w8v:6/6j\:kdG$$Ifl4@87O94 la f4 & F-$If V$If^V & F'$If $$Ifa$:kd;G$$Ifl4:O9O94 la f4$If P6Q6Y6`6e6f6p6v666666666666666666666Z Z Z Z LLLLLRRRRRRRR $$Ifa$ $$Ifa$66666666667777777777"7,71797:7RRRRRRRRRRRR $$Ifa$ $$Ifa$:7;78$IfkdG$$Ifl Vz(#R&|),815@82 p$ ****O9((((4 la F7G78 8 888,8.8082848P8R8T8V8X8l8n8p8z8|8~888888888888888888888889999989ڸڭڢڗڌځjQhFUj5QhVm]UjPhVm]UjaPhVm]UjOhVm]UjMhFUjIhFUhjhUhVm]jhFUmHnHujhVm]Uj=IhVm]U2828V8~88889>9f9 $$Ifa$$If 89:9<9>9@9T9V9X9b9d9h999:":e:f:::;;<<<<-=K=N=Q=R=d=y=z={===迻yjbZbh 1B*phjh 1Uh 15<B*OJQJphh<B*OJQJphh 1<B*OJQJhphhQD\<B*OJQJphh 1<B*OJQJph h 15hQD\hih 1jhFUmHnHujSh_jUhjjhjUhVm]jhVm]UjShFU#f9h9j9 $$Ifa$kd7T$$Ifl Vz(#R&|),815@82 p$ ****O9((((4 la j9l9n9p9r9t9v9x9z9|9~99999:::e:LRRRR`9v:))%$If5kdX$$Ifl4|))4 laf4 %$$Ifa$%dPFfV $$Ifa$$Ife:f::L;;<<<N=O=P=)v:X5kd'Y$$Ifl4|))4 laf4:$ Pi I W*P X !$%`'$If^`a$5kdX$$Ifl4|))4 laf4 P=Q=|=}=~=====j9$ Mi I W*P X !$%`'$If^`a$= wn$If^n`5kdvY$$Ifl4|))4 laf4%$Ifh^hh^h==AAAAAAAAAAAAAABIBCCCCCCDDD>EEFF&FPFRFTFZFFFFFϿϺϺϿϢϿϒ}uh B*phjh B*UphhaB*phha5B*CJOJQJphh 1<B*phhQD\<B*OJQJph h 15h 1B*phjh 1Uh 1h 15<B*OJQJphh 1<B*OJQJphh 1<B*CJOJQJph&=M>>"??AAAA)VPh^h5kdY$$Ifl4|))4 laf4%$If7$ J I W*P X !$%`'$If^`a$5$ Mi I W*P X !$%`'h$If^ha$AAAAAABBCM5$ Mi I W*P X !$%`'$If^a$9$ Mi I W*P X !$%`'$If^`a$5kdZ$$Ifl4|))4 laf4%$Ifh^hCCCCCCDD D>EE)~~|h^hh^h5kdcZ$$Ifl4|))4 laf4%$If9$ Mi I W*P X !$%`'$If^`a$ EEEFVFXFZFFFFGGmggVa!$If#$IfGkd[$$Ifl(X)   X)4 lap  x$Ifgdah^h5kdZ$$Ifl4|))4 laf4 FFFFFFFFGGGG2G4G6G@GBGDGJGLG`GbGdGrGtGvGGGGGGGG¼{nfVnnfjn]hs"haX5Uhs"haX5jhs"haX5Uh(|haX5jhF5UmHnHuj\ht 8ht 85U ht 85jht 85UhaX haX5CJ haXCJhahaB*ph#jhFB*UmHnHphujh B*Uph$j[h h B*Uph GDGFGHGJGLGbGdGfGrGtGGv:' v:|V|Vtv:j|' v:$If#$Ifpkd\$$Ifl\(. [ X)4 la$If$If GGGGGGG()KB8jB8j9! $Ifgda $Ifgda9kd^$$Ifl (X)X)4 la $Ifgd(|pkd]$$Ifl\(. [ X)4 laGGGGGGGGGGGGGH,,,:,>,@,^,`,b,d,x,z,|,,,,,,,,,,,,ξ֯򧠧wjbhs"h8q5jhs"h8q5UjhFUmHnHuj`h31Uh31jh31Uh8q h8q5CJ h8qCJUjhF5UmHnHuj^h|/ha5Uh|/ha5jh|/ha5Uhaha5CJOJQJhaCJOJQJh(|%GGGH,,,<,j? jz(j@(j9kd#`$$Iflh(X)X)4 larkd_$$Iflh\5(  X)4 la $Ifgda $IfgdaDHS Local Office Approval: Name and Title:  FORMTEXT       Signature: Date:  FORMTEXT       FORMTEXT       Distribution of Plan:   MACROBUTTON [b2] "Click Here and Type"  The local office shall approve, or disapprove, in writing, the PWSP for a child in purchased foster care or residential care. The Purchase of Service (POS) agency is responsible for all elements of the service plan in cases where they have accepted responsibility for providing family services per the DHS-3600 (RFF 3600) contract. The local office is responsible for reporting requirements only when the POS agency has not accepted total case responsibility. The report from the local office should not duplicate the POS agency report, but should address those areas for which the POS agency is not responsible per the DHS-3600 contract. Signing the PWSP submitted by the POS agency indicates approval. The approved PWSP is to be returned to the POS agency within seven days of receipt; a copy is retained in the childs case record. The local office is responsible for knowing what services are being purchased from the POS agency and for monitoring compliance with the DHS-3600. When a noncompliance situation is identified, it is to be brought to the attention of the POS agency both verbally and in writing. If efforts to resolve the area of conflict locally are not successful, the situation is to be brought to the attention of the appropriate Zone Office. If Zone Office is unable to intervene successfully, then the Office of Child and Family Services is to be involved. (See CFF 914, Monitoring Worker Responsibilities for more information.) Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.AUTHORITY: P.A. 280 of 1939. RESPONSE: Voluntary. PENALTY: None DHS-68 (Rev. 10-08) Previous edition obsolete. MS Word  PAGE 1 DHS-68 (Rev. 10-08) Previous edition obsolete. MSWord <,>,@,`,b,,,,V!v:' v: $Ifgd8q $Ifgd8q #$Ifgd8q9kdp`$$Iflh(X)X)4 la,,,,,,,,,VVzv:qjq' v:h $Ifgd8q $Ifgd8q $Ifgd8q #$Ifgd8qpkda$$Ifl\(. [ X)4 la,,,,,,,,,,,- ---@-B-D-F-H-l------.../ȵȣzvhZhLhQD\<B*OJQJphhVg<B*OJQJphh 1<B*OJQJphhFh_jB*phjh_jUh_jhaCJOJQJha5CJOJQJhajhFUmHnHujYch8qUjh8qUh8qhs"h8q5jhF5UmHnHujhs"h8q5Uj.bhs"h8q5U,, ----|(A8(v: $Ifgda:kdOd$$Ifl4(X)X)4 laf4 $Ifgd8q $Ifgd8qpkdb$$Ifl\(. [ X)4 la--@-B-D-F---1133(j(j~upnnnngd_j^gd_jdgd_j7kdd$$Ifl(X)X)4 la $Ifgda7kdd$$Ifl(X)X)4 la />0A011395:5z5{5|5}55555555555555HHHƼttcaTchg"hF0J8CJaJU!jhg"hF0J8CJUaJhg"hFCJaJhFCJaJhFhF0J8CJmHnHuhF0J8CJjhF0J8CJU hFCJhc8CJOJQJh9CJOJQJhT#CJOJQJ h 15h 1hB:h^JaJhQD\<B*OJQJphh 1<B*OJQJph3:5W5l5z5{5|5}5~5555nf0*jf0*jf0*jf0*jf0*jf$a$gdT#qkd0e$$Ifl0H|){04 la $If^ $If^ $$Ifa$ 555 H H H H\\\.\V\~\\$If $$Ifa$$If$a$gdT#, !")d`gdp, !|)d8gdr PAGE 7 HH H H H H\\\\ \*\,\.\0\D\F\H\R\T\V\X\l\n\p\z\|\~\\\\\\\\\\\ƿtg_jhb UjghLX5UjfhLX5UjhLX5Uj1fhH5U hLX5j5UmHnHujeh:5U5 j5U CJOJQJhc8CJOJQJhFhg"hFCJaJ!jhg"hF0J8CJUaJhF0J8CJaJmHnHu% 0/ =!@"`#$`%" 00/ =!@"`#$`% 0/ =!@"`#$`%" 00/ =!@"`#$`%* 00&P/ =!@"@#$%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h% 0/ =!@"`#$`%" 00/ =!@"`#$`% 0/ =!@"`#$`%" 00/ =!@"`#$`% 0/ =!@"`#$`%" 00/ =!@"`#$`%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%'&P0= /!"#$h%$&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%* 00&P/ =!`"@#$h%# 0&P/ =!"`#$%* 00&P/ =!`"@#$h%' 0&P/ =!`"@#$h%DFCWorkerLoadNo,Enter the assigned FC Worker's Load Number CaseInfo.MAIN$$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / / /  / 4D FCWorkerName(Enter the name of the assigned FC Worker$$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / / /  / 4DPOSAEnter Court ID number assigned.$$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / / /  / 4DPOSWEnter Court ID number assigned.$$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / / /  / 4DCofREnter PS Case Number $$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / / /  / 4DCOJEnter PS Case Number $$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / / /  / 4DCDNEnter PS Case Number $$If!vh5l5 5#vl#v #v:V l+5l5 5/ / / /  4$$If!vh5l5 5#vl#v #v:V l+5l5 5/ 4D Text30$Enter Starting Date of Report PeriodD "Enter Ending Date of Report Period$$If!vh55Q55]#v#vQ#v#v]:V l+55Q55]4D &Enter the date the report is completed]$$If!vh55@$#v#v@$:V l+55@$4G$$If!vh5+#v+:V l+5+4K$$If!vh5+#v+:V l+5+4c$$If!vh55#v#v:V l4+554f4]$$If!vh5*5*%#v*#v*%:V l+5*5*%4$$If!v h5585/555d5855 #v#v8#v/#v#v#vd#v8#v#v :V l+, 5585/555d5855 4D0 ChildNameEnter Child's NameAddIdentInfoAutoD Text32Enter Child's Date of BirthD$Text33Enter Child's Case NumbervD$Text56vD Text57vD Text57vD Text58vD Text59vD Text60$$If!v h5585/555d5855 #v#v8#v/#v#v#vd#v8#v#v :V l+5585/555d5855 4K$$If!vh5T*#vT*:V l+5T*4$$If!vh5*5:5>5B5z 5 #v*#v:#v>#vB#vz #v :V l +,5*5:5>5B5z 5 4p<D Enter Child's NameD$Enter Child's Date of BirthD Enter Child's Case NumberjD Df Dropdown5  Parental HomeLic/Unlic RelativeLegal Guardian Adoptive HomeLic Unrelated Foster Home Ind LivingUnrelated CaregiverOtherDf Dropdown5  Parental HomeLic/Unlic RelativeLegal Guardian Adoptive HomeLic Unrelated Foster Home Ind LivingUnrelated CaregiverOther$$If!vh5*5:5>5B5z 5 #v*#v:#v>#vB#vz #v :V l+5*5:5>5B5z 5 4p<X$$If!vh5T*#vT*:V l+5T*4p $$If!vh5*5:55F#v*#v:#v#vF:V l+,5*5:55F4p(vD Text61vDText62Df Dropdown6 ReunificationAdoption Guardianship!Permanent Placement with Relative*Placement in Another Planned Living ArrangDf Dropdown7  Emancipation by Age 19!Permanet Placement w/ Relative(s) Return HomeAdoption$Termination of Parental Rights/Adopt!Permanent Foster Family AgreementMaintain Own Placement Guardianship$$If!vh5*5:55F#v*#v:#v#vF:V l+5*5:55F4p(K$$If!vh5T*#vT*:V l+5T*4DY$Child's Address (if not foster home)]$$If!vh5Y 5#vY #v:V l+5Y 54Df Dropdown4Native American? Select response. To add additional child(ren) click or tab to Tribal Affiliation field and click Add Child Info button YesNoUnknownPendingDTribeUIf yes, Tribal Affiliation. To add additional child(ren) click Add Child Info button$$If!vh55"55#v#v"#v#v:V l (+55"554p([$$If!vh5T*#vT*:V l4+5T*/ 4f4M$$If!vh5T*#vT*:V l4+5T*4f4c$$If!vh55'#v#v':V l4+55'4f4s$$If!vh555$#v#v#v$:V l+555$4$$If!vh555 5#v#v #v:V l55 54aL$$If!vh5*#v*:V l5*4a$$If!vh5 5T55 5_#v #vT#v#v #v_:V l*5 5T55 5_4c$$If!vh55Q(#v#vQ(:V l4*55Q(4f4y$$If!vh555%#v#v#v%:V l4*555%4f4y$$If!vh555%#v#v#v%:V l4*555%4f4~$$If!vh555%#v#v#v%:V l4555%4af4h$$If!vh55y(#v#vy(:V l455y(4af4h$$If!vh55n(#v#vn(:V l455n(4af4$$If!vh5555?#v#v#v#v?:V l5555?4ah$$If!vh55y(#v#vy(:V l455y(4af4p$$If!vh555%#v#v%:V l455%4af4$$If!vh5555"#v#v#v":V l4555"4af4x$$If!vh5555"#v#v":V l455"4af4x$$If!vh5555"#v#v":V l455"4af4$$If!vh5555 5~ 55#v#v#v #v~ #v#v:V lV555 5~ 554aDChild AddChildRowjDjD jD $$If!vh5555 5~ 55#v#v#v #v~ #v#v:V lV555 5~ 554a$$If!vh5555 5~ 55#v#v#v #v~ #v#v:V lV555 5~ 554ax$$If!vh5555"#v#v":V l455"4af4q$$If!vh5555"#v#v":V l55"4q$$If!vh5555"#v#v":V l55"4q$$If!vh5555"#v#v":V l55"4x$$If!vh5555"#v#v":V l455"4af4$$If!vh55555X #v#v#vX :V l4555X 4af4$$If!vh55555X #v#v#vX :V l4555X 4af4$$If!vh55555X #v#v#vX :V l4555X 4af4x$$If!vh5555"#v#v":V l455"4af4x$$If!vh5555"#v#v":V l455"4af4~$$If!vh5555"#v#v":V l4,55"4af4$$If!vh55555* #v#v* :V l455* 4af4$$If!vh55555* #v#v* :V l455* 4af4$$If!vh55555M #v#vM :V l455M 4af4$$If!vh55555* #v#v* :V l455* 4af4$$If!vh55555* #v#v* :V l455* 4af4$$If!vh55555* #v#v* :V l455* 4af4p$$If!vh555%#v#v%:V l455%4af4h$$If!vh55y(#v#vy(:V l455y(4af4h$$If!vh55y(#v#vy(:V l455y(4af4$$If !vh5W5W5\5E #vW#v\#vE :V lO95W5\5E 4a x$$If !vh55h53 #v#vh#v3 :V lO955h53 4a $$If !vh5W5$55A #vW#v$#v#vA :V l4O95W5$55A 4a f4$$If !vh5W5$55A #vW#v$#v#vA :V l4O95W5$55A 4a f4L$$If !vh5O9#vO9:V lO95O94a V$$If !vh5O9#vO9:V l4$O95O94a f4V$$If !vh5O9#vO9:V l4$O95O94a f4$$If !vh555*5 55#v#v#v*#v #v#v:V l4$O9555*5 554a f4$$If !vh555*5 55#v#v#v*#v #v#v:V l4$O9555*5 554a f4$$If !vh555*5 55#v#v#v*#v #v#v:V l4$O9555*5 554a f4$$If !vh555*5 55#v#v#v*#v #v#v:V l4$O9555*5 554a f4$$If !vh555*5 55#v#v#v*#v #v#v:V l4$O9555*5 554a f4R$$If !vh5O9#vO9:V l4O95O94a f4R$$If !vh5O9#vO9:V l4O95O94a f4R$$If !vh57#v7:V l4O9574a f4X$$If !v h52 5p5$ 55*5*5*55 5 *#v2 #vp#v$ #v#v*#v#v #v *:V lO952 5p5$ 55*55 5 */ /  / / / / / 4a vD6Text11PDf C1. Medical/Physical Health C2. Mental Health and Well-Being*C3. Fam and Unrel Caregiver Rel/Attachment C4. EducationC5. Substance UseC6. Sexual BehaviorC7. Life Skills#C8. Peer/Adult Social RelationshipsC9. Cultural/Comm IdentC10. Ind LivingC11. Soc/Emot DevelopC12. Cog/Intell DevelopC13. Phys/Motor DevelopC14. Lang/Comm SkillsC15. Child DevelopmentDf AD=Alcoh/Drg Abuse RehabOT=Other Program NeedsJT=Job Trng/Empl AssistFR=Reunification Svs DC=Day CarePS=Parenting Skills TrngMH=Mental Health SvsMD=Medical SvsIL=Independent Living Svs ED=EducationTH=Individual/Group TherHS=Homemkr Svs or Par AidDV=Dom Violence ProgFC=Fam Couns/Outrch Couns WP=WraparoundjD6jDjDjDdDfD1 = Service Unavailable 2 = Continue Services 3 = Refused Services 1=Svs Unavlbl 2=Cont Svs 3=Refusd Svs4=NewDf S=Satisfact U=UnsatisfDPopUpPrompt2.MAINX$$If !v h52 5p5$ 55*5*5*55 5 *#v2 #vp#v$ #v#v*#v#v #v *:V lO952 5p5$ 55*55 5 */ /  / / / / / 4a  $$If !v h555p5$ 55*5*5*5 5 5 *#v#v#vp#v$ #v#v*#v #v #v *:V lO9555p5$ 55*5 5 5 *4a kdU$$Ifl 8 Vz(#R&|),815@8p$ ****O9,,,,4 la M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4M$$If!vh5)#v):V l45)4f4DText16AddYouthSignaturef$$If!vh5X)#vX):V l   X)5X)4p D- AddSignaturesEnter Foster Care Worker's NameAddSignatureAuto$$If!vh5. 5[55 #v. #v[#v#v :V lX)5. 5[55 4vD Text55$$If!vh5. 5[55 #v. #v[#v#v :V lX)5. 5[55 / / / 4K$$If!vh5X)#vX):V l X)5X)4D(Enter FIA Local Office Name$$If!vh5 555 #v #v#v#v :V lhX)5 555 / 4K$$If!vh5X)#vX):V lhX)5X)4K$$If!vh5X)#vX):V lhX)5X)4D- fiasignatureEnter Foster Care Worker's NameAddFIASignatureAuto$$If!vh5. 5[55 #v. #v[#v#v :V lX)5. 5[55 4vD Text55$$If!vh5. 5[55 #v. #v[#v#v :V lX)5. 5[55 / / / 4DText51@Enter Worker name, Typist initials, or other information desiredM$$If!vh5X)#vX):V l4X)5X)4f4G$$If!vh5X)#vX):V lX)5X)4G$$If!vh5X)#vX):V lX)5X)4$$If!vh5{5#v{#v:V l05{54ajDF8@8 g"Normal_HmH sH tH J@J Heading 1$$@&a$5CJOJQJT@T Heading 2$s@&]^s5CJOJQJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List XOX User Input 10ptd8(CJOJQJkHLOL User Input 11ptd$ CJOJQJ\O\ User input 12ptd((5CJOJQJkHPO"P BLANKLINEdx5CJOJQJkHTO2T Captions 6ptd(CJ OJQJkHDO1BD Captions 6pt bold5`OR` Captions 6pt boxd<5CJ OJQJkHDO1bD Captions 6pt Nbox<DO1rD Captions 7pt dtCJDOqD Captions 7pt Bold5`O` Captions 7pt boxdt<5CJOJQJkH^O^ Captions 7pt NBoxdt<CJOJQJkHPOP Captions 8pt d`CJOJQJkH^O^ Captions 8pt Bold d`5CJOJQJkHFOF Captions 8pt box <DOD Captions 8pt NboxPPOP E Captions 9pt dLCJOJQJkHJOJ Captions 9pt Bold dLCJFOF Captions 9pt Box !dDO"D Captions 9pt Nbox"5PO2P Captions 10pt#d`( OJQJkHLO1BL Captions 10pt 2 line $<^OR^ Captions 10pt Bold%d8(5OJQJkHXObX Captions 10pt box&d`P OJQJkHHOQrH Captions 10pt Nbox'P5BOB Date 08pt(CJOJQJkH6O6 Date 09pt)CJ6O6 Date 10pt*CJ2O2 Date 11pt+CJJ @J Footer,dt !CJOJQJkHROR Form Title 10pt-$d8a$ OJQJkH^O^ Form Title 10pt Bld.$d8a$5OJQJkHVOV Form Title 11pt/$d$a$CJOJQJkHLOL Form Title 11pt Bld0d$CJVOV Form Title 12pt1$da$CJOJQJkHbO"b Form Title 12pt Bld2$da$5CJOJQJkH4@24 Header 3 !TOBT Letter Text 10pt4$d$a$ OJQJkHFOARF Letter Text 11pt5dCJXObX Letter Text 12pt6$da$CJOJQJkHHO!rH Small Blank Line 7CJ.)@. Page Number`O` CoSuppaddress9d8(OJQJ_HkHmH sH tH O c:VOV Address1;d8(OJQJ_HkHmH sH tH ZOZ CountyName<d8(OJQJ_HkHmH sH tH R@ Body Text Indent 2n=$ Snw I W*P X !$%`'w^w`a$CJ>'> Comment ReferenceCJFOFUser Input 09pt? mHnHuHOH User Input 07pt@< 5;CJ4@4  Comment TextA\O"\ EnteredCareBd8(5OJQJ_HmH sH tH H2H  Balloon TextCCJOJQJ^JaJ@j@ &Comment SubjectD5\XOQX aCaptions 9pt CharCJOJQJ_HmH sH tH )UE r T =imLyCp 7Ly6c1I v !!M(+,10^0f2244-6X6>L !L EL fL L L L  M 7M `M M M M  N 6N WN {N N N N O .O ZO O O O P -P YP P P P Q ,Q XQ Q Q Q R +R WR R R R S *S PS |S S S S &T OT {T TT -AB^r*+,@TUVfz{|}~456BC #$8L`t2MNbv=>Rfx%&'(+  #$%&'()STUVWXYZ[_rstzB C D E p q r s v     Q R S T  #  (12345I]q-.Z9:;<=ghijknijklmPJKLwxyz{|~q_ g1256>@ABCnopqru  56789:=~ JKLwxyz{|456abcdefi}/0125\F G H I t u v y D!|!}!~!!!!!!!!!!!!"""""""""""""""""""""""##!#"#'#;#@#I#N#t#u#{##########$$/$0$6$P$U$e$i$t$u$v$w$$$$%|%%P&&&&&&&&&&&&&&&&&&&&&&&&&&''' '''''&','4'5'6'>'E'F'G'H'I'S'\']'^'_'d'n's'{'|'}'''''''(()(=(>(?(@(A(B(C(D(E(F(G(H(I(J(K(L(M((((((q))** + +++++,,,),*,k,l,,V--^..0/00010\0]0^000/10111c2d2e2f22223444444455555,5-5.5/505;5<5=5C5D5X5Y5Z5[5\5s5t55555555555555555555555566666*6+6,6-6X6Y699<<===>>>>> > > >M>N>>>>20 0 0 0 /0 0 0 0 /0 0 0 0 /0 0 0 0 /0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0!0 00 00 0 0 0 0 0 0 0 0 00 0!0 0 0 0 0 0 0 0 0 0 0 ?0 ?0 ?0 ?0 ?0 ?0 ?0 ?0 ?0 0 ?0 0 0 0 0 0 0 0 0 ?0 ?0 ?0 ?0 ?0 ?0 0 ?0 0 0 0 0 0 0 ?0 ?0 ?0 ?0 0 ?0 0 0 ?0 0 0 ?0 0 ?0 0 0 0 0 0 0 00 0 0 0 0 0 000 0 00 0 0 0 0 0 0 000000 0 0 0 0 0 0 0 0 0 0!00!0 0 0 00 0 00 000 0 00 0 00 000 0 0 0 0000 0 00000 0 0 0 0 0 00 0 0 0 00 0 0 0 0 0000 0 0 00 0 0 0000 0 0 00 0 0 0 0  0 0 00!0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 00 0 0 00000/ 00 00 01 02 03 00 0 00