ࡱ> ~ @ bjbj  ؝؝!B-PPPPPPP4nQlR ,DZZZ5p $5RP55PPZZPZPZPP ZW 5 Z0 mmPPPPmP+"Mey+++XHidX4Hi FOSTER CARE / JUVENILE JUSTICEFC / JJ Case #: FORMTEXT      ACTION SUMMARYFC / JJ Case Name: FORMTEXT      Michigan Department of Human ServicesDHS FC / JJ Worker Load #: FORMTEXT      DHS FC / JJ Worker Name: FORMTEXT      PS Case Name: FORMTEXT      PS Case #: FORMTEXT      Court ID#: FORMTEXT      POS Agency Name: FORMTEXT      POS Agency Worker Name: FORMTEXT      Date Completed: FORMTEXT      I. Type of Action (check as many as apply)Effective Date: FORMTEXT       FORMCHECKBOX 1. Child Replacement FORMCHECKBOX 4. Parent Move FORMCHECKBOX 2. Caseworker Change FORMCHECKBOX 5. Termination from Foster Care Placement FORMCHECKBOX 3. Foster Care Case Closing FORMCHECKBOX 6. Juvenile Justice Case ClosingII. Child InformationName FORMTEXT        FORMTEXT      DHS Case Number: FORMTEXT      Sex: FORMCHECKBOX M FORMCHECKBOX FRace: FORMDROPDOWN Funding Source: FORMDROPDOWN Check if Ethnicity Hispanic / Latino FORMCHECKBOX DOB: FORMTEXT      III. Caseworker ChangeFormer Caseworker Load #: FORMTEXT      New Caseworker Load #: FORMTEXT      IV. Parent or Child Move SummaryParent Name: FORMTEXT        FORMTEXT      Prior Address: FORMTEXT      New Address: FORMTEXT      Supplemental FORMTEXT      Supplemental FORMTEXT      City: FORMTEXT      City: FORMTEXT      State: FORMTEXT   Zip Code: FORMTEXT      State: FORMTEXT   Zip Code: FORMTEXT      Former Telephone:( FORMTEXT    )  FORMTEXT      New Telephone:( FORMTEXT    )  FORMTEXT      Child Name: FORMTEXT        FORMTEXT      Moved From: FORMTEXT      Moved To: FORMTEXT      Supplemental FORMTEXT      Supplemental FORMTEXT      City: FORMTEXT      City: FORMTEXT      State: FORMTEXT   Zip Code: FORMTEXT      State: FORMTEXT   Zip Code: FORMTEXT      Former Phone:( FORMTEXT    )  FORMTEXT      New Phone:( FORMTEXT    )  FORMTEXT      Foster Home Provider (MPS#): FORMTEXT      Foster Home Provider (MPS#): FORMTEXT      Primary Provider: (MPS#): FORMTEXT      Primary Provider: (MPS#): FORMTEXT       A. Foster Care / Juvenile Justice Continues to be Appropriate for the Following Reason(s) (check as many as apply): FORMCHECKBOX 1. Children remain at risk if returned to the parental home. FORMCHECKBOX 4. Juvenile Justice Treatment Goals have FORMCHECKBOX 2. No interested relatives for placement.not been Completed FORMCHECKBOX 3. No appropriate relative placements. FORMCHECKBOX 5. Juvenile Justice Court Order FORMCHECKBOX 6. Juvenile Justice Behavior ProblemsB. Reason for Replacement or Termination from Foster Care / Juvenile Justice (check as many as apply): FORMCHECKBOX 1. Behavioral Problems FORMCHECKBOX  8. AWOL FORMCHECKBOX 2. Emergency or Temp. Placement FORMCHECKBOX  9. Supervisor approved prior to replacement FORMCHECKBOX 3. Placement with Relative Caregiver FORMCHECKBOX 10. Notice given to provider of intended change  FORMCHECKBOX 4. Residential Placement FORMCHECKBOX Of placement on FORMTEXT       FORMCHECKBOX 5. Return HomeDate FORMCHECKBOX 6. Problems in Foster Family11. Other (specify): FORMTEXT       FORMCHECKBOX 7. Independent Living FORMTEXT      Replacement and/or Termination preparation appropriate to the childs capacity to understand has beenconducted in the following way:  MACROBUTTON [b2] "Click Here and Type"   If notice not given to provider of intended change within 14 days, explain why not.  MACROBUTTON [b2] "Click Here and Type"   C.Placement InformationPlacement Selection CriteriaRank each from 1 4; 1 being the reason(s) most important to the placement decision, 3 the least important and 4 not applicable. FORMDROPDOWN The case plan which includes the goal of permanence. FORMDROPDOWN The physical, emotional, educational and safety needs of the child(ren). FORMDROPDOWN Proximity to the child(ren)s family. FORMDROPDOWN Placement within relative family network of the child(ren). FORMDROPDOWN Placement with siblings of the child(ren). FORMDROPDOWN The child(ren)s and child(ren)s familys religious preference. FORMDROPDOWN The least restrictive, i.e., most family like setting. FORMDROPDOWN The continuity of relationships. FORMDROPDOWN Availability of placement resources for the purposes of timely placements. FORMDROPDOWN Expressed preferences for placement by the foster child.If any Placement Selection Criteria are not met, explain why not.  MACROBUTTON [1] Click Here and Type  V. Information related to the care and supervision of the child or termination from Foster Care was shared with:1. FORMCHECKBOX Mother on: FORMTEXT      via: FORMCHECKBOX letter, FORMCHECKBOX face to face, or FORMCHECKBOX telephone2. FORMCHECKBOX Father on: FORMTEXT      via: FORMCHECKBOX letter, FORMCHECKBOX face to face, or FORMCHECKBOX telephone3. FORMCHECKBOX New Provider on: FORMTEXT      via: FORMCHECKBOX letter, FORMCHECKBOX face to face, or FORMCHECKBOX telephone4. FORMCHECKBOX DHS/Referring Worker on: FORMTEXT      via: FORMCHECKBOX letter, FORMCHEC`bvxzB D J z |  " 6 8 : D F H J b d x ºײײײjhh3t{Ujh3t{Ujh3t{Ujh3t{Uh_\h3t{5 h_\5jh_\U h3t{5jhG[UmHnHujh_\Uh_\jh_\Uh3t{5@`]kd$$If9FHz+2 "3     4 9a.$If$If *$Ifgd_\D z .]kd$$If9FHz+2 "3     4 9a.$If$If (d$If]kd>$$If9FHz+2 "3     4 9a   H 9$If]kd$$If9FHz+2 "3     4 9a.$If$If (d$IfH J L b 1]kd$$If9FHz+2 "3     4 9a.$If$If9$If]kd4$$If9FHz+2 "3     4 9ax z |      N P d f h r t v x J L ` b d n p ·լ·աՙޙՙޙjhKYAUj0hKYAUhKYAjhKYAUj< h3t{Uj h3t{Uh3t{5CJOJQJh3t{OJQJjX h3t{Uh3t{ h3t{5jhG[UmHnHujh3t{Ujh3t{U/   .$If^$If]kd $$If9FHz+2 "3     4 9a.$If$If9$If   N v x -`kd $$Ifl4FHz+2 "     4 laf4 .$If^$If`kdv $$Ifl4FHz+2 "     4 laf4x z | ~ $If.$If9$IfJkd $$If90+N$3 4 9a$If * J r NHHB.$If!$If9kd$$If9t++3 4 9a$Ifpkd$$If9\"+NtR3 4 9ap r z |   2 4 6 f h DFbdf  024>@BHd|h_\jh3t{Uh3t{OJQJjhG[UmHnHuj6h3t{UjdhG[UjvhG[UjhG[UjhG[UjJhG[UjfhG[Ujh3t{Uh3t{ h3t{CJ0r t v x z `XPHXP$If.$If$If:kd$$If94++3 4 9af4$If]kd|$$If9FP!+u 3     4 9a    8 d f `XPXP.$If$Ifkd"$$If9ֈ='+vvtvv3 4 9a$If BDhh`XP`XP$If.$If$Ifkd$$If9ֈ='+vvtvv3 4 9ae_"<kd$$If94t++3 4 9af4$IfkdP$$If94ֈ='+vvtvh3 4 9af4Bdztntn.$If$If$If:kd$$If94++3 4 9af4$If7kdx$$If9++3 4 9a!$If dfz|~DFbdf󛗌ڛj.)h3t{Uj&hKYAUhKYAjhKYAUj$hG[Uj"hG[Uj,hG[UjhG[UjhG[UjhG[UmHnHujh3t{Uh3t{jh3t{U0 {uoiiouiouoi.$If$If$Ifkd8$$If9r=)r'+vIu 3 4 9a "$Dhj.$If $<$Ifa$.$If$If$IfFf!UOICICO.$If$If$Ifkd%$$If9֞=ro(,*+v\ +p3 4 9ahb%<kd'$$If94t++3 4 9af4$Ifkd.'$$If9ֈ=r,*+v\ +p3 4 9aLNPRT~xrlrl.$If$If$If<kd($$If94t++3 4 9af4$If7kdl($$If9++3 4 9a!$If tv,.BDFPRrtڹڮڣژړڈj2h3t{U h3t{5jH1h3t{Uj0h3t{Uj2/h3t{Uj.h3t{Uj-h3t{Uj,h3t{Uh3t{jhG[UmHnHujh3t{Uj*h3t{U5  P{u82!$If<kdZ+$$If94t++3 4 9af4$Ifkd*$$If9r=\  +v U  3 4 9aPRTVXZttnhb.$If$If:$IfLkd,$$If9t0=+v_*3 4 9a$If7kd+$$If9++3 4 9a,T^XRLRL.$If$If:$If<kd".$$If94t++3 4 9af4$If]kd-$$If9F=$ +vx"3     4 9aTVXr{uoioi.$If$If:$Ifkd/$$If9r=!+vq,G{3 4 9a H{uoioi.$If$If:$Ifkd2$$If9r= +vq,03 4 9a "68:DFHJZ\prtxz "$&RThjlrtxzjk8h3t{Uj7h3t{Uj5h3t{UjR5h3t{Uj4h3t{UjN4h3t{U h3t{5j&3h3t{Uh3t{jh3t{UjhG[UmHnHu:HJLZ|${uoioioioi.$If$If:$Ifkd3$$If9r= +vq,03 4 9a $&(/)$Ifkd_6$$If9 = j 6$+vq*p0f3 $$$$4 9a(*,P.$If$If:$If<kdk7$$If94t++34 9af4  .0DFHRTVXlnpz|"$8:<FHdfz|~ڹڮڣژڍj @h3t{UjQ?h3t{Uj=h3t{UjC=h3t{Uj;h3t{Uj;;h3t{Uj9h3t{Uh3t{jhG[UmHnHujh3t{Uj9h3t{U6{u82:$If<kd:$$If94t++3 4 9af4$Ifkd!:$$If9r=; +v  3 4 9a.~|v9<kd<$$If94t++3 4 9af4$Ifpkd?<$$If9\=$*+vh"x3 4 9a:$If.$If$If"Jdikd>$$If9r=!+vq{3 4 9a.$If$If:$If {ulclc .$Ifgd $Ifgd:$Ifkd@$$If9r=!+vq{3 4 9a   "$(*@BVXZdfvx 246@BjvGhCBUjFhCBUj"EhCBUjDhCBUjDhCBUjiChCBUjBhUjhG[UmHnHujAhCBUjhCBUhCB8 ,@hv{uoioioioi.$If$If:$IfkdB$$If9r=!+vq{3 4 9a /) $Ifgd:$IfkdE$$If9 = j!KO$+vq*3*M3 $$$$4 9aDZJric:$IfkdJ$$If9r=pz+v3-"3 4 9a $Ifgd .$Ifgd B\^rtv|~ JL`bdnpv *,4: h3t{CJ h3t{5 h3t{5CJh3t{j&NhUjTMhCBU hCB@jKhUjJhCBUjIhUjhG[UmHnHujdHhUjhCBUhCB3rtv.{ulclc .$Ifgd $Ifgd:$IfkdL$$If9r=N f!+v O  6 3 4 9a.0248:{u860:$If<kdO$$If94t++3 4 9af4$IfkdN$$If9r=N f!+v O  6 3 4 9a:)gyjdd^V^<$If.$If:$If7kdP$$If94t++4 9af4$IfHkdP$$If940=+v\*4 9af4:Z$If^Z` &'(ghvwx   45CDElm{|}%&'ABPQR`aopqj\hG[Uj$[hG[UjZhG[UjLWhG[UjUhG[UjThG[U h3t{5jvShG[UjQhG[UjPhG[Uh3t{jh3t{U5ye__YSI .$If^.$If.$If:$IfkdR$$If9ֈ=)B+vvvh4 9a<$If 4FgmggaYaY<$If.$If:$IfkdJT$$If9ֈ=)B+vvvh4 9aghijkl~mgga[aS<$If$If.$If:$IfkdV$$If9ֈ=)B+vvvh4 9amg1+:$If5kdX$$If94++4 9af4$IfkdFX$$If9ֈ=)B+vvvh4 9a(@ASwqqkcqk<$If.$If:$If5kdY$$If94++4 9af4$IfEkdBY$$If90=+v\*4 9a!$If S]^_`rNHHB:<$If.$If:$Ifkd\$$If9֞=)'+vvvvv4 9a <$If^Bkd^$$If9֞=)'+vvvvv4 9a <$If^.$If:$If !WXfgh   2 4 6 n p !!!!"!$!,!~jhh3t{UjghG[UjfhG[UjhG[UmHnHujdh3t{UjchG[UjhbhG[Uj`hG[Uh_\j_hG[Uh3t{jh3t{Uj]hG[U1"TUVWiFkda$$If9֞=)'+vvvvv4 9a.$If:$If<$Ifi z<$If^z.$If:$If<$If    8 X GAA;3<$If.$If:$Ifkd2e$$If9ִ=)'t"+vvvvva%     4 9aX Z \ ^ h j l 7kd g$$If9ִ=)'+vvvvvv    4 9a 6 $If^6 :$Ifl n &!<$If.$If:$If&!(!*!,!P!~!D>>80<$If.$If:$Ifkdi$$If94ִ=)'!+vvvvv     4 9af4,!.!J!L!N!!!!!!!!i"j"|""""""###### #$#&#(#)#?#A#_#a#b#########.$|q|jmqhG[UjhlhJU$hlhJ<B*CJOJQJph hOhJhOhlhJ5CJOJQJhlhJCJOJQJ hlhJh3t{B*phjhG[UmHnHujvkh3t{Uj`jhG[Uh3t{jh3t{U,~!!!!!!!;5$Ifkdl$$If9ִ=)'+vvvvvv    4 9a.$If:$If!!!!!B"C"D"E"F"Qkkd6m$$If9\=)+vvvp'4 9a$If:$If5kdl$$If94++4 9af4 F"f"g"h"i"""tj\\.$If]^ .]^~kdm$$If9r=)&+vvvs4 9a:$If$If"""""""""Onkdn$$If94\=)+vvvp'4 9af4$If:$If:2kd+++4 9a.$If]^ $#%#&#)#?#xofZ $$Ifa$gdJ !$IfgdO $IfgdJkdco$$Ifl4rD * 4 laf4?#@#A#B#_# $$Ifa$gdJ $IfgdJ`kdo$$Ifl4F* '    4 laf4_#`#a#b## $$Ifa$gdJ $IfgdJ`kdwp$$Ifl4FD*@'    4 laf4#####.$~d($IfgdJ .$IfgdJ $IfgdJ`kdp$$Ifl4FD*@'    4 laf4.$/$0$B$C$$yp $IfgdCB .$IfgdJ $IfgdJskdr$$Ifl4\K*h! 4 laf4.$0$1$?$@$A$B$C$$$$$$$$$$$$$$$$$%%%)%*%+%,%-%X%Z%[%i%j%k%l%m%%%%%%%%%%%% & & &&&0&2&3&j:hG[UjC}hG[Uj8{hG[UjQyhG[UjJwhG[UjmuhG[UjlshG[U hlhJjhlhJUhlhJCJOJQJ:$$$$$$yp $IfgdCB .$IfgdJ $IfgdJskdt$$Ifl4\K*h! 4 laf4$$$$$%yp $IfgdCB .$IfgdJ $IfgdJskdv$$Ifl4\K*h! 4 laf4%%%,%-%X%yp $IfgdCB .$IfgdJ $IfgdJskdx$$Ifl4\K*h! 4 laf4X%Y%Z%l%m%%yp $IfgdCB .$IfgdJ $IfgdJskdz$$Ifl4\K*h! 4 laf4%%%%%%yp $IfgdCB .$IfgdJ $IfgdJskd|$$Ifl4\K*h! 4 laf4%%%&&0&yp $IfgdCB .$IfgdJ $IfgdJskd~$$Ifl4\K*h! 4 laf40&1&2&D&E&&yp $IfgdCB .$IfgdJ $IfgdJskdn$$Ifl4\K*h! 4 laf43&A&B&C&D&E&&&&&&&&&&&''(')'*';'P'Q'R'T'U''''''''''( ( (((6(8(:(L(N(j(l(n((ּzjhG[UjˈhG[UjhG[UmHnHujh3t{UjhG[Ujh3t{Uh3t{hlhJB*phj hG[UhlhJCJOJQJjhlhJUjhG[U hlhJ0&&&&&&yp $IfgdCB .$IfgdJ $IfgdJskdu$$Ifl4\K*h! 4 laf4&&&&&&v $$Ifa$gdJ $IfgdJskd|$$Ifl4\K*h! 4 laf4&&&''('y+Mkd$$Ifl40*'4 laf4 $IfgdCB $IfgdJskd$$Ifl4\K*h! 4 laf4(')'S'T'U''''''T:kd[$$If94++4 9af4:$If7kd $$If9++4 9a!$IfgdJ . ]^ gdJ .]^gdJ .]^gdJ ''''((<(L(p(((((((()6)@)d)t)))))))Ffѓ:$IfFfA.$If$If(((((((((())$)&)()2)4)@)B)^)`)b)t)v)))))))))))***B*D*X*Z*\*f*h*t*v*******jhG[Uj;h3t{UjhG[UjhG[UjhG[Uj[hG[UjhG[UmHnHujh3t{UjQhG[UjShG[Uh3t{jh3t{U3)) *B*j*t*****+&+(+*+0+T++++++2VjlnFf:$IfFfa.$If$If***** +++0+2+N+P+R+T+Z+++++++++++++++, 24PRTtvjhG[Uj!hG[Uj[hG[UUjhG[UjhG[UmHnHujٞh3t{Uh_\jqhG[UjshG[Uh3t{jh3t{UjhG[U2KBOX face to face, or FORMCHECKBOX telephone5. FORMCHECKBOX Relative Caregiver FORMTEXT      via FORMCHECKBOX letter, FORMCHECKBOX face to face, or FORMCHECKBOX telephoneInformation shared with new care giver(s) includes (check as many as apply):1. FORMCHECKBOX Assigned Worker 8. FORMCHECKBOX Behavior Management2. FORMCHECKBOX Reason(s) Child Removed 9. FORMCHECKBOX Visitation Expectations3. FORMCHECKBOX Case Plan10. FORMCHECKBOX Consent to Treatment Card4. FORMCHECKBOX Description of Behavioral Characteristics and Needs11. FORMCHECKBOX School Enrollment Form5. FORMCHECKBOX Medical/Dental/Psychological Needs and/or Files12. FORMCHECKBOX Abuse/Neglect History6. FORMCHECKBOX Interactions with Parents/Siblings13. FORMCHECKBOX Offense History7. FORMCHECKBOX School Records14. FORMCHECKBOX Relative Caregiver Pamphlet (Pub 457)Information given to youth at case closing due to Independent Living:1. FORMCHECKBOX Birth Certificate3. FORMCHECKBOX Medical Passport2. FORMCHECKBOX Social security Card4. FORMCHECKBOX Aftercare Services PamphletVI. For Termination From Foster Care or Closing:(Complete A. and B. for Case Closing Summary Only) A. Report Period Covered: FORMTEXT      B. Social Work Contacts Since Last USP:  MACROBUTTON [b2] "Click Here and Type"   1.Reason for Closure (if applicable):  MACROBUTTON [b2] "Click Here and Type"   2.Summarize services that were provided during care:  MACROBUTTON [b2] "Click Here and Type"   3.Summarize services currently being provided:  MACROBUTTON [b2] "Click Here and Type"   4.List services and needs still to be met and provisions for follow up services, if any:  MACROBUTTON [b2] "Click Here and Type"   5.Was medical information given to parents or next placement: FORMCHECKBOX Yes FORMCHECKBOX No6.Was termination or closure explained to all parties: FORMCHECKBOX Yes FORMCHECKBOX No7.If termination is unplanned, summarize the reasons and circumstances surrounding the termination.  MACROBUTTON [b2] "Click Here and Type"   Foster Care Worker Signature:Date:  FORMTEXT      Supervisor Signature:Date:  FORMTEXT      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-69 (Rev. 7-08) Previous edition obsolete. MSWord  PAGE 1 nt"FhB!$If:kd$$If94++4 9af4:$IfFf.$If$If "$@BDhj>PRnprRTprtڹڴڴکڞړڈ}jhG[UjhG[UjhG[UjӮhG[UjǭhG[U h3t{5jhG[UjhG[UjShG[Uh3t{jhG[UmHnHujh3t{Ujh3t{U1BDFHJPtsmgmmgm.$If$If:kdo$$If94++4 9af4:$IfJkd$$If90=+ve*4 9a HRvUOICIIC.$If$If:$Ifkdٯ$$If9֞h)}+Kv4 9avLF@.$If:$Ifkd˲$$If94֞h)}+Kv4 9af4$IfRTprtBD`bd(*FHJ 24PRTFHd󢚢hNjhG[UjhG[Ujh_\Uh_\jhG[UjټhG[UjhG[UjhG[UjͷhG[UjhG[UjhG[Uh3t{jh3t{U2HJLRvF@:$Ifkd$$If94֞h)}+Kv4 9af4$If.$If 8:<BfF@:$Ifkdٸ$$If94֞h)}+Kv4 9af4.$If$Iff "(F@:$Ifkd$$If94֞h)}+Kv4 9af4.$If$If(LF@:$Ifkd$$If94֞h)}+Kv4 9af4$If.$If *2V .$Ifgd_\ $Ifgd_\.$If$IfRLLF@$If.$If:$Ifkd$$If94֞h)}+Kv4 9af4<>@4MkdY$$If940h+:*4 9af4!$If:$Ifpkd$$If9\h)+Kvy'4 9a@FjFkd$$If94֞h)}+Kv4 9af4.$If$Ifdfh8:VXZj&(*Nxz|(*,h賮荅yyyh3t{B*phh3t{jh3t{U h3t{5jhG[5UmHnHujh_\5U h_\5jh_\5Uh_\B*CJphjhG[UjhG[UjhG[Uh_\jh_\UjhG[U/28\.$If$If:$IfRL:$Ifkd$$If94֞h)}+Kv4 9af4hj:$If7kd$$If9++4 9a!$If:kdo$$If94++4 9af4jln"J]kd-$$If9F=N +v T    4 9a.$If!$IfJkd$$If90=+ve*4 9a"$&(~QO!2kd/$$If9++4 9a .$If^ .]^`kd$$If94F=+vL    4 9af4:$If.02zzG2kd$$If9++4 9a .$If^:[kd$$If94F9+[\    4 9af4:$If !{$If^{ !$$If]a$24:~~ .$If^[kdW$$If94F+    4 9af4:$If !{$If^{ !$$Ifa$:bdfhUK .$If^[kd-$$If94Fe+1    4 9af4:$If !{$If^{ !$$Ifa$:2kd$$If9++4 9ahj|~VXtvx&(DFHTVrtvTVX|$&hj~󲮣󲮊j[hKYAUjhG[UmHnHujhKYAUhKYAjhKYAU h3t{5jhG[UjhG[UjhG[UjhG[Uh3t{B*phh3t{jh3t{U6xz|gEkd$$If90+'4 9a :{$If^{ !$$Ifa$:2kd$$If9++4 9a .$If^ Vz:$If!$If.$If !{$If^{ !$$Ifa$:2kdk$$If9++4 9a D>:$Ifkd$$If94ִ"P$:'+vu_    4 9af4&JRTx~:$If!$If.$If !{$If^{ !$$Ifa$5kd$$If94++4 9af4 D>>:$Ifkd$$If94ִ"P$:'+vu_    4 9af4RTV`ZL>.8$If]^8.$If]^.h^hEkd$$If90+'4 9a !{$If^{ !$$Ifa$Ekd$$If90=+v\*4 9a(.$If$If:$If:2kd$$If9++4 9a(*,XZfhzrzrll.$If$If:$If~kd$$If9r=,"+v4 9azn $If^.$If~kd$$If9r=,"+v4 9a8b~vll $If^ $If^ $$Ifa$tkd$$Ifl4(0r+r'094 laf4~HH H"H$H&HBHveaSIhSUCJOJQJjhSUCJOJQJUhSU!j3hSUCJOJQJUhSUCJOJQJjhSUCJOJQJUh]2h)ahD h)aCJaJh]20J8CJaJmHnHu!jhD h)a0J8CJUaJhD h)a0J8CJaJh0J8CJaJh)a0J8CJaJh3t{ h3t{5hG[h3t{aJhhG[hG[aJh~$HHHlHHHrppnljhf$ !+d`gdD  dgdG[tkd$$Ifl40r+r'094 laf4 .&P:pG[/ =!"#8$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@* 00P P / =!@"`#$%' 0P P / =!@"`#$%* 00P P / =!@"`#$%+ 0&P/ =!"#$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@. 00&P/ =!"#$%@+ 0&P/ =!"#$%@D FCCaseNoEnter FC Case number. CaseInfo.MAIN$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / / /  / 44 9aD FCCaseNameEnter FC Case Name.$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / / /  / 44 9aDFCWorkerLoadNo'Enter in assigned worker's load number.$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / / /  / 44 9aD FCWorkerName Enter in assigned worker's name.$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / / /  / 44 9aD PSCaseName'Enter PS case name. (Primary caretaker)$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / /  44 9aDPSCaseNoEnter PS case number.$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / /  44 9aDCourtNoEnter Court ID Number$$If!vh552 5"#v#v2 #v":V 93 552 5"/ / / /  44 9aDPOSA%Enter Purchase of Service Agency Name$$If!vh552 5"#v#v2 #v":V l4 552 5"/ / / / /  4af4DPOSW%Enter Purchase of Service Worker Name$$If!vh552 5"#v#v2 #v":V l4 552 5"/ / / / /  4af4p$$If!vh5N5$#vN#v$:V 93 5N5$44 9aD DateCompleted$Enter date assessment was completed.$$If!vh5N5t5R5#vN#vt#vR#v:V 93 5N5t5R544 9al$$If!vh5+#v+:V 9t3 5+/ 44 9atD Text9$$If!vh55u5 #v#vu#v :V 93 55u5 44 9a`$$If!vh5+#v+:V 943 5+44 9af4DeChildReplacement.Check if child was moved to another placement.De ParentMoveCheck if parent was moved.Terminationfromfoste$$If!vh5v5v5t5v5v5#vv#vt#vv#v:V 93 5v5t5v544 9a DeCaseworkerChange.Check if FC case was assigned to a new worker.FostercarecaseclosinDeTerminationFromFoste&Check if child has been returned home.Lastname$$If!vh5v5v5t5v5v5#vv#vt#vv#v:V 93 5v5t5v544 9aDeFosterCareCaseClosin%Check if foster care case is closing. ParentMoveDeTerminationFromFoste&Check if child has been returned home.Lastname$$If!vh5v5v5t5v5h5#vv#vt#vv#vh#v:V 943 5v5t5v5h544 9af4d$$If!vh5+#v+:V 94t3 5+44 9af4Z$$If!vh5+#v+:V 93 5+44 9a`$$If!vh5+#v+:V 943 5+44 9af4DLastName First capitalEnter Child's Last NameD FirstName First capitalEnter Child's First Name.xD FCCaseNo1Enter FC case number.$$If!vh5v55I55u #vv#v#vI#v#vu :V 93 5v55I55u 44 9aDeSexMCheck if child is male.DeSexFCheck if child is female.Df Dropdown1Select child's race. 1 White2 Black or African American 3 American Indian/Alaskan Native4 Asian(5 Native Hawaiian/Other Pacific Islander6 Unable to Determine$$If!v h5v55v5v5v55v5v5 5 +5 #vv#v#vv#v#vv#v #v +#v :V 943 5v55v55v5 5 +5 44 9af4kd$$If94 =)w cr+vvvvvv+3 ,,,,4 9af4Df Dropdown2Select Funding Source 1=Own family/adoptive family 2=Title IV-E3=County Child Care Fund4=State Ward Board & Care5=Temporary Foster Care6=Self-supportingDeTerminationFromFoste&Check if child has been returned home.Lastname$$If!vh5v55\ 5+555p#vv#v#v\ #v+#v#v#vp:V 93 5v55\ 5+555p44 9aD DOBEnter child's date of birth.$$If!vh5v55\ 5+55p#vv#v#v\ #v+#v#vp:V 93 5v55\ 5+55p44 9ar$$If!vh5+#v+:V 94t3 5+/ 44 9af4Z$$If!vh5+#v+:V 93 5+44 9ad$$If!vh5+#v+:V 94t3 5+44 9af4DFormerCaseworker.Enter former caseworker's first and last name.D NewCaseworker+Enter new caseworker's first and last name.$$If!vh5v5 5U5 5 #vv#v #vU#v #v :V 93 5v5 5U5 5 44 9ad$$If!vh5+#v+:V 94t3 5+44 9af4Z$$If!vh5+#v+:V 93 5+44 9at$$If!vh5v5_*#vv#v_*:V 9t3 5v5_*44 9aDLastNameParentEnter the parent's last name.DFirstNameParentEnter parent's first name.$$If!vh5v55x"#vv#v#vx":V 93 5v55x"44 9ad$$If!vh5+#v+:V 94t3 5+44 9af4D PriorAddress7Enter parent's prior street address or P.O. box number. Supplemental1D NewAddress5Enter parent's new street address or P.O. box number. Supplemental2$$If!vh5v5q5,5G5{#vv#vq#v,#vG#v{:V 93 5v5q5,5G5{44 9aD Supplemental1Enter Apt. #. or P.O. numberD supplemental2Enter Apt. #. or P.O. Number$$If!vh5v5q5,505#vv#vq#v,#v0#v:V 93 5v5q5,50544 9anDCity Enter city.StatetDnewcity Enter city.NewState$$If!vh5v5q5,505#vv#vq#v,#v0#v:V 93 5v5q5,50544 9aDState#Enter two digit state abbreviation.D ZipEnter zip code (+4 if known).AreaCodeDnewstate#Enter two digit state abbreviation.D newzipEnter zip code (+4 if known). NewAreaCode $$If!v h5v5q5*55p50555 f#vv#vq#v*#v#vp#v0#v#v#v f:V 93 5v5q5*55p50555 f44 9ad$$If!vh5+#v+:V 94t35+44 9af4DAreaCodeEnter area code.D PhoneNumber4Enter the 7 digit phone number (Example: 373-1234). NewAddresswD NewAreaCodeAdd the area code.DNewPhoneNumber4Enter the 7 digit phone number (Example: 373-1234).$$If!vh5v55 55 #vv#v#v #v#v :V 93 5v55 55 44 9ad$$If!vh5+#v+:V 94t3 5+44 9af4D LastNameChildEnter the child's last name.DFirstNameChildEnter child's first name.$$If!vh5v55h"5x#vv#v#vh"#vx:V 93 5v55h"5x44 9ad$$If!vh5+#v+:V 94t3 5+44 9af4DPriorAddressChild7Enter parent's prior street address or P.O. box number. Supplemental3DNewAddressChild5Enter parent's new street address or P.O. box number. Supplemental4$$If!vh5v5q555{#vv#vq#v#v#v{:V 93 5v5q555{44 9aD Supplemental3Enter Apt. #. or P.O. numberD Supplemental4Enter Apt. #. or P.O. number $$If!vh5v5q555{#vv#vq#v#v#v{:V 93 5v5q555{44 9aDPriorCityChild Enter city.D NewCityChild Enter city.$$If!vh5v5q555{#vv#vq#v#v#v{:V 93 5v5q555{44 9aDPriorStateChild#Enter two digit state abbreviation. PriorZipChildD PriorZipChildEnter zip code (+4 if known).PriorAreaCodeChildD NewStateChild#Enter two digit state abbreviation.D NewZipChildEnter zip code (+4 if known).NewAreaCodeChild $$If!v h5v5q5*55355*55 M#vv#vq#v*#v#v3#v#v*#v#v M:V 93 5v5q5*55355*55 M44 9aDpriorareacodechildEnter the Area Code.Dpriorphonechild3Enter the 7 digit phone number (Example: 373-1234).DNewAreaCodeChildEnter the Area Code.D newPhoneChild3Enter the 7 digit phone number (Example: 373-1234).$$If!vh5v535-55"#vv#v3#v-#v#v":V 93 5v535-55"44 9aDFormerFosterHomeFHNo6Enter previous Foster Home's FH number, if applicable.DNewFosterHomeFHNo1Enter new foster home's FH number, if applicable.$$If!vh5v5 5O 5 56 #vv#v #vO #v #v6 :V 93 5v5 5O 5 56 44 9aDPrimaryProviderCANo!Enter Primary Provider CA number.DPrimaryProviderCANo1!Enter Primary Provider CA number.$$If!vh5v5 5O 5 56 #vv#v #vO #v #v6 :V 93 5v5 5O 5 56 44 9ad$$If!vh5+#v+:V 94t3 5+44 9af4l$$If!vh5v5\*#vv#v\*:V 945v5\*44 9f4Z$$If!vh5+#v+:V 94t5+44 9f4DeCheck12BCheck if Children remain at risk if returned to the parental home.DeCheck12BCheck if Children remain at risk if returned to the parental home.$$If!vh5v5v5v55h5#vv#v#vh#v:V 95v55h544 9DeCheck13/Check if No interested relatives for placement.$$If!vh5v5v5v55h5#vv#v#vh#v:V 95v55h544 9De,Check if No appropriate relative placements.DeCheck12BCheck if Children remain at risk if returned to the parental home.$$If!vh5v5v5v55h5#vv#v#vh#v:V 95v55h544 9DeCheck12BCheck if Children remain at risk if returned to the parental home.$$If!vh5v5v5v55h5#vv#v#vh#v:V 95v55h544 9V$$If!vh5+#v+:V 945+44 9f4f$$If!vh5v5\*#vv#v\*:V 95v5\*44 9V$$If!vh5+#v+:V 945+44 9f4"DeCheck10VCheck if Reason for Replacement or Termination from Foster Care is Behavioral problemsDeb8GCheck if Reason for Replacement or Termination from Foster Care is AWOL$$If!vh5v5v5v55v5v5#vv#v#vv#v:V 95v55v544 92Deb2cCheck if Reason for Replacement or Termination from Foster Care is emergency or temporary placementDeb8GCheck if Reason for Replacement or Termination from Foster Care is AWOL$$If!vh5v5v5v55v5v5#vv#v#vv#v:V 95v55v544 9 Deb3ZCheck if Reason for Replacement or Termination from Foster Care is placement with relativeDeb8GCheck if Reason for Replacement or Termination from Foster Care is AWOL$$If!vh5v5v5v55v5v5#vv#v#vv#v:V 95v55v544 9Deb4XCheck if Reason for Replacement or Termination from Foster Care is residential placementDeb9HCheck if Reason for Replacement or Termination from Foster Care is OtherD $Enter date assessment was completed.$$If!vh5v5v5v55v5v5a5% #vv#v#vv#va#v% :V 95v55v5a5% / 44 9Deb5NCheck if Reason for Replacement or Termination from Foster Care is return home$$If!vh5v5v5v55v5v5v5#vv#v#vv#v:V 95v55v544 9(Deb6^Check if Reason for Replacement or Termination from Foster Care is problems with foster familyDb9OtherEnter detail for Other$$If!vh5v5v5v55v5v55 #vv#v#vv#v#v :V 945v55v55 / 44 9f4Deb7UCheck if Reason for Replacement or Termination from Foster Care is independent livingDb9other2Enter detail for Other$$If!vh5v5v5v55v5v5v5#vv#v#vv#v:V 95v55v5/ 44 9V$$If!vh5+#v+:V 945+44 9f4v$$If!vh5v5v5v5p'#vv#vp':V 95v5p'44 9$$If!vh5v5v5v55s#vv#v#vs:V 95v55s44 9P$$If!vh5+#v+:V 95+44 9|$$If!vh5v5v5v5p'#vv#vp':V 945v5p'44 9f4U$$If!vh5+#v+:V 9+5+44 9a$$If!vh55555 #v#v#v#v :V l45555 4f4y$$If!vh5 55'#v #v#v':V l45 55'4f4y$$If!vh55@5'#v#v@#v':V l455@5'4f4y$$If!vh55@5'#v#v@#v':V l455@5'4f4nDf Dropdown2j2. Placement Selection Criteria: select appropriate rank - case plan which includes the goal of permanence 1234$$If!vh555h5!#v#v#vh#v!:V l4 555h5!4f4jDfq2. Placement Selection Criteria: select appropriate rank - Physical, emotional and safety needs of the child(ren) 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4FDf_2. Placement Selection Criteria: select appropriate rank - Proximity to the child(ren)'s family 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4pDft2. Placement Selection Criteria: select appropriate rank - Placement within kinship family network of the child(ren) 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4PDfd2. Placement Selection Criteria: select appropriate rank - Placement with siblings of the child(ren) 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4tDfv2. Placement Selection Criteria: select appropriate rank - child(ren)'s and child(ren)'s family's religious preference 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4`Dfl2. Placement Selection Criteria: select appropriate rank - Least restrictive, i.e., most family like setting 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f44DfV2. Placement Selection Criteria: select appropriate rank - Continuity of relationships 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4pDft2. Placement Selection Criteria: select appropriate rank - Availability of placement resources for timely placements 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4pDft2. Placement Selection Criteria: select appropriate rank - Availability of placement resources for timely placements 1234$$If!vh555h5!#v#v#vh#v!:V l4 ,555h5!4f4$$If!vh555h5!#v#v#vh#v!:V l4 555h5!4f4c$$If!vh55'#v#v':V l455'4f4P$$If!vh5+#v+:V 95+44 9V$$If!vh5+#v+:V 945+44 9f4\DeCheck22sInformation related to the care and supervision of the child or termination from Foster Care was shared with MotherD Text22#Date information shared with motherDeCheck23&Check if information shared via letterDeCheck24(Check if information shared face to faceDeCheck25(Check if information shared by telephone&$$If!v h5v5v5v5A 555v55 h5 m5 u5 #vv#vA #v#v#vv#v#v h#v m#v u#v :V 95v5A 555v55 h5 m5 u5 44 9kd$$If9  =)jd&zO$%+vvvA vhmu00004 9aNDesInformation related to the care and supervision of the child or termination from Foster Care was shared with fatherD )Enter date information shared with fatherDeCheck29&Check if information shared via letterDeCheck30(Check if information shared face to faceDeCheck31(Check if information shared by telephone&$$If!v h5v5v5v5A 555v55 h5 m5 u5 #vv#vA #v#v#vv#v#v h#v m#v u#v :V 95v5A 555v55 h5 m5 u5 44 9kd$$If9  =)jd&zO$%+vvvA vhmu00004 9aZDeyInformation related to the care and supervision of the child or termination from Foster Care was shared with new providerD #Enter date shared with new providerDeCheck32&Check if information shared via letterDeCheck33(Check if information shared face to faceDeCheck34(Check if information shared by telephone&$$If!v h5v5v5v5A 555v55 h5 m5 u5 #vv#vA #v#v#vv#v#v h#v m#v u#v :V 95v5A 555v55 h5 m5 u5 44 9kd9$$If9  =)jd&zO$%+vvvA vhmu00004 9ahDeInformation related to the care and supervision of the child or termination from Foster Care was shared with FIA/referral workerD +Enter date shared with FIA/Referring workerDeCheck35&Check if information shared via letterDeCheck36(Check if information shared face to faceDeCheck37(Check if information shared by telephone&$$If!v h5v5v5v5A 555v55 h5 m5 u5 #vv#vA #v#v#vv#v#v h#v m#v u#v :V 95v5A 555v55 h5 m5 u5 44 9kd$$If9  =)jd&zO$%+vvvA vhmu00004 9anDeInformation related to the care and supervision of the child or termination from Foster Care was shared with kinship family membersD .Enter date shared with kinship family membersDe&Check if information shared via letterDe(Check if information shared face to faceDe(Check if information shared by telephone&$$If!v h5v5v5v5A 555v55 h5 m5 u5 #vv#vA #v#v#vv#v#v h#v m#v u#v :V 95v5A 555v55 h5 m5 u5 44 9kdw$$If9  =)jd&zO$%+vvvA vhmu00004 9aV$$If!vh5+#v+:V 945+44 9f4f$$If!vh5v5e*#vv#ve*:V 95v5e*44 9V$$If!vh5+#v+:V 945+44 9f4 DeCheck38KCheck if Information shared with new care giver(s) includes Assigned WorkerDeOCheck if Information shared with new care giver(s) includes behavior management$$If!vh55K5v5555#v#vK#vv#v#v#v#v:V 955K5v555544 9DeSCheck if Information shared with new care giver(s) includes reason(s) child removedDeSCheck if Information shared with new care giver(s) includes visitation expectations$$If!vh55K5v5555#v#vK#vv#v#v#v#v:V 9455K5v555544 9f4DeECheck if Information shared with new care giver(s) includes Case PlanDeUCheck if Information shared with new care giver(s) includes consent to treatment card$$If!vh55K5v5555#v#vK#vv#v#v#v#v:V 9455K5v555544 9f4FDeoCheck if Information shared with new care giver(s) includes description of behavioral characteristics and needs DeRCheck if Information shared with new care giver(s) includes school enrollment form$$If!vh55K5v5555#v#vK#vv#v#v#v#v:V 9455K5v555544 9f4>DekCheck if Information shared with new care giver(s) includes medical/dental/psychological needs and/or files D