Request Case File Format

LEFT SIDE

Top Section/Tab Middle section/Tab Bottom section/Tab SERVICES ON-GOING ASSESMENT & ADMINISTRATION ADMINISTRATION (cont.) Service Recordings CASE PLAN Foster Care Review Board (FCRB) Requests DSS-1259 Benefits Action Transmittal Transfer Summary CPS CQA, Continuous Quality Worker Letters (outgoing) DSS-1260 Title IV-E Child Support Form Case Transfer form Assessment Form or ADT DCBS-1 Informed Consent & Release of Information DCBS-1261 Title IV-E Action Sheet DSS-1262 Title IV-E Eligibility/Reimbursability Summary Closing Summary APS CQA Continuous Quality Records DCBS-1265 Redetermination Status Report Aftercare Plan Assessment Form or ADT DCBS-1A Informed Consent & Release of Information DCBS-1273 Establishing a CFC Trust Fund P&P-1282 Family Case Plan Records Supplement DCBS-1274 Change in Payee (including the OOHC section) DPP- 886 PCC Client Inter-Agency Referral Form DPP-1279 Information for OOHC Placements Prevention Plan DPP-886A Application for Referral and Needs DPP-1299 Referral for Emergency Weatherization Visitation Contracts Assessment Notice of Child Fatality/Near Fatality Signature Sheets DSS-892 Daily Routine for Preschool Age Children Fatality/Near Fatality 60 Day Internal Review DPP-293 Adult Personal DSS-893 Daily Routine/School Age Child Template Development Plan Child Behavior Checklist (Achenbach) KC-01 Kinship Care Program Statement of Rights and DPP-294 Individual Adult Safety Reiss Scales for Children’s Dual Diagnosis & Scales for Responsibilities Plan Independent Behavior KC-02 Kinship Care Respite Request Form KC-02A Kinship Care Respite Services Receipt Form Concurrent planning All Children Review Program (CRP) forms KIM-78KC Kinship Care Financial Assistance Application Forms/Matrix (Remember to IV-E Preventative Assistance Investigator’s Checklist for Kinship Care chronologically file with the Clothing Letter Ongoing Worker’s Checklist for Kinship Care dated assessment just Other Financial Forms Kinship Care Checklist immediately before the case Financial related correspondence (i.e. medical bills, Region Log for Kinship Care Start Up plan). KHSA emergency fund) Relative Resource Information Sheet Homemaker Approval DCBS-173 Benefits Change Notice Transportation-Non-committed Client Approval Homemaker Contract LIHEAP Preventative DPP-1276 Relative Home MA Cards Evaluation-Outline DCBS-1B Application for Services

*Note: Each section should be in chronological order with most recent dates at top. RIGHT SIDE Top section/Tab Middle section/Tab Bottom section/Tab PROFESSIONAL PROFESSIONAL(cont.) LEGAL INVESTIGATION DPP-1251A Child Placement History Drug Screens Courts Orders, Reports & Calendars Correspondence to CPS Multiple Response Matrix Log DCC-86 Referral for Child Care Assistance Judges/Courts from CHFS Protective Services Investigative Findings Adult DPP-106A Authorization for Routine PAFS 628 Exchange of Information Petitions Abuse, Neglect, or Exploitation Health Care and Authorization for Non- HIPAA forms All AOC Forms Notification of Protective Services Investigative Routine Health Care DCC-85 Authorization for Child Care Court Ordered Home Evaluations Findings Adult Abuse, Neglect, or Exploitation DPP-106B Initial Physical and Assistance ECO, EPO, and DVO Initial Investigative CQA or ADT Behavioral Health History Educational/Vocational Related Material Affidavits DPP-152 CPS Substantiated Investigation DPP-106C Child Medical History and DPP-103 Application for Tuition All judicial orders Notification Letter Annual Physical Exam Assistance for Youth Committed to CHFS- All correspondence to and from the court DPP-152A CPS Unsubstantiated Investigation DPP-106D Medical Appointment DCBS All absent parent search documentation Notification Letter DPP-106E Dental Care Educational Assessment Referral Form All forms related to establishment of paternity DPP-153 CPS FINSA Notification Letter DPP-106F Visual Screening Educational Assessment Referral Letter DPP-111A Foster Home Contract Supplement DPP-153A CPS Family Not In Need of Services DPP-106G Mental Health Services Educational Assessment Thirty Day DPP-114 Level of Care Schedule Notification Letter DPP-106H Medication Administration Follow-up Referral Letter DSS-158 Petition-Voluntary Termination of Parental Rights JC3 Form Independent Living Information DSS-160 Statement of Representatives of the Cabinet for Any investigation photos DPP-106I Methamphetamine Exposure Impact Plus Addendum Families & Children Intake/Investigation related correspondence Medical Administration Record Impact Plus Request for Services DSS-161 Request for Involuntary Termination of Parental DPP-154 Service Appeal Request DPP-106 Impact Plus (correspondence) Rights DPP-154A Notice of Intended Action DPP-1268 Medical Information for Impact Request for services DSS-167 Consent to Voluntary Commitment DPP-155 CAPTA Appeal Newborn Infants Form (correspondence) DSS-177 Report of Filing of Petition For Involuntary TPR DPP-156 Central Registry Check DSS-1293 Rehab Approval Form Independent Living Referral Form DSS-215 Consent to Adoption DPP-157 Child Abuse or Neglect Check DSS-1294 Rehab Monthly Service Insurance Information DSS-1266 Affidavits of Reasonable Efforts DPP-1300 Service Complaints Monthly Report Report RIAC Request Absent Parent Search Form Documentation from professionals/ collaterals CHFS Out-of-Home Care Service Plan DPP-130 Daily Record of Events (DROE) Criminal Record Check pertinent to the investigation for Physical Health Parenting class material Investigation Report Concerning Custodial Arrangements Client Photographs (Non-investigative) (correspondence) for the Child Social Security Cards (copies) DPP-1020 Safety Net Assessment Confidentiality Report to Circuit Court on the Petition to Birth Certificates (copies) DPP-1021 Safety Net Verification form Adopt a Child VS37 Application for Birth Certificates DPP-1022 Safety Net Report Predispositional Investigation Report DPP-117 Verification of DCBS AC-1 Transmittal Memo Expiration of Temporary Custody Order Marriage/Divorce Presentation Summary Letters from service providers, Presentation Summary and Attachments including therapists Confirmation Notice for DNR Psychological Evaluations Internal/External Referrals External Service Provider Information *Note: Each section should be in chronological order with most recent dates at top.