Division of Family and Children Services s1
Total Page：16
File Type：pdf, Size：1020Kb
Division of Family and Children Services
CHILD ABUSE AND NEGLECT REPORT – FORM 431
Case Number: County Name: Person Starting Date Reported: Investigatation:
CARETAKER INFORMATION
Name of Parent(s)/Caretaker(s) SSN Date of Birth Gender
Secondary Caretaker must be added as household member.
Address: City: State: Zip:
INCIDENT INFORMATION
Case Determination Status: Where Did the Maltreatment Occur? 01-Substantiated Open 01-Victim’s Home 02-Substantiated Closed 02-Other Private Home 03-Unsubstantiated Open 03-Center Based Daycare 04-Unsubstantiated Closed 04-Family Based Daycare 05-Pending 05-Residential Foster Care Home 06-Transferred within Georgia 06-Group Home Foster Care 07-Transferred outside Georgia 07-Family Foster Home-DFCS 08-Family Foster Home-Non DFCS Reported By: 09-Other Institution (School) 01-Custodial Parent/Guardian 10-Other 02-Relative 03-Neighbor/Friend Previous CPS History: 04-Non-Custodial Parent Yes 05-Religious Leader/Staff No 06-Lawyer 07-Unknown If Yes, was most recent closure less than 1 year prior to the current report? 08-Other Non-Mandated Person Yes 09-Anonymous No 10-School Personnel 11-Law Enforcement/Court Family Violence: 12-Hospital/Clinic 01-Not Alleged 13-Physician, Dentist, Podiatrist, Nurses 02-Alleged but Unsubstantiated 14-Professional Counselors, Social Workers 03-Substantiated-Children Emotion Abuse 15-DHR Staff (Not TANF Sanction Related) 04Substantiated-Children Physical Abuse 16-Day Care Center 05-Substantiated-Children No Substantiated Maltreatment 17-Alleged Maltreater 18-Victim Adult Substance Abuse Status: 19-TANF (Sanction Related) 01-Not Alleged 02-Alleged Unsubstantiated Special Circumstances: 03-Alleged Substantiated 01-No Special Circumstances 04-Not Alleged But Substantiated 02-Case Opened as result of “Safe Place for Newborns” Law 03-Case Opened as result of “Physician Taking Child into Custody” Law Substance Abuse Type: 04-Case Opened on order of Juvenile Court-No Maltreatment Alleged 01-Alcohol 05-Other out of Home Arrangement 02-Prescription Medicine 03-Controlled Substance 04-Alcohol and Prescribed Medicine 05-Alcohol and Controlled 06-Prescribed Medicine and Controlled Substance 07-All Types
Systems and Methods, Inc Page 1 of 7 Rev. 03/14/2007 Division of Family and Children Services
CHILD ABUSE AND NEGLECT REPORT – FORM 431 (Child Maltreatment Information)
Case Number:
HOUSEHOLD MEMBERS INFORMATION
Foster Child 2nd MT Date of Hispanic Family Name SSN Gender Race County & Case# CT Child Birth Ethnicity Role* (If Applicable)
Select secondary caretaker (2nd CT) and any maltreated children (MT Child).
Family Role Code: Race: Parent Grand Parent Other Relative Black/African American Child Grandchild Live in Boyfriend/Girlfriend Asian Spouse Aunt/Uncle Roommate Native Hawaiian/Other Pacific Islander StepChild Neice/Nephew Other White Sibling Cousin American Islander/Alaska Native Unable to Determine
Systems and Methods, Inc Page 2 of 7 Rev. 03/14/2007 Division of Family and Children Services
CHILD ABUSE AND NEGLECT REPORT – FORM 431 (Child Maltreatment Information)
NOTE: Page 3 of this form must be filled out separately for each Maltreated Child. Make additional copies as needed.
Case Number: County Name: Child Name: Date Reported:
Alleged Maltreater Relationship: Physical Injury: Child Ever Adopted? 01-Biological Parent 01-No Physical Injury Yes 02-Adoptive Parent 02-Physical Injury – No Treatment Needed No 03-Step Parent 03-Physical Injury – Treatment Needed Unknown 04-Foster Parent (DFCS) 05-Foster Parent (Non-DFCS) Child Death: ADOPTION DETAILS 06-Grandparent 01-Child Alive Adoption Agency Type: 07-Uncle/Aunt 02-Death Attributed to Substantiated Abuse Public 08-Biological Sibling 03-Death Attributed to Substantiated Neglect Private 09-Other Relative 04-Death-No Maltreatment 10-Baby Sitter/Child Care Living Arrangement (at time of maltreatment): Adoption Type: 11-Other Non-Related Person 01-With Family (Not Foster Care) Domestic 12-Relationship Unknown 02-Foster Care Relative International 13-Live in Boyfriend or Girlfriend 03-Foster Care Non-Relative 14-School Personnel State Adoption Finalized: 04-Group Home/Institution-Under DFCS 15-Residential Facility Staff (DFCS) Supervision 16-Residential Facility Staff (Non-DFCS) 05-Group Home/Institution-No DFCS Supervision County Adoption Finalized: (if 06-Unknown Custody transferred to the Dept. thru Georgia): Court Action: Is Child a legal Military Dependent: Yes Country of Origin (if international Yes No adoption): See page 5 for list No of countries. Unknown
Special Characteristics – Check All That Apply:
Not Yet Diagnosed None Diagnosed Diagnosed Mental Retardation Mild Diagnosed Mental Retardation Moderate Diagnosed Mental Retardation Severe Diagnosed Mental Retardation Profound Diagnosed Vision/Hearing Impaired Diagnosed Physically Disabled Diagnosed Emotionally Disturbed Other Medically Diagnosed Condition Behavior Alcohol Abuse/Child Drugs/Other Substance Abuse
A-Alleged AU-Alleged but Unsubstantiated AS-Alleged and Substantiated NAS- Not Alleged but Substantiated
Neglect: A AU AS NAS Emotional Abuse: 01-Malnourishment/Failure to Thrive Verbal Threats A AU AS NAS 02-Abandonment/Rejection Bizarre Discipline (Non Physical) 03-Inadequate Supervision
04-Inadequate Food, Clothing, Shelter Other Abuse:
05-Inadequate Health, Medical Care 01-Case Opened on Report; however, No Maltreatment Reported 06-Emotional/Psychological Neglect 07-Educational/Cognitive Neglect Physical Abuse: 08-Gunshot 01-Fractures, Dislocations, Sprains 09-Suffocation/Drowning 02-Intracranial Injury, Skull Injury 10-Birth Addicted/Birth Exposed 03-Spinal Cord, Nerve Damage 04-Subdural Hematoma Sexual Abuse: 05-Internal Chest, Abdomen, Pelvic Injury 01-Exhibitionism/Voyeurism 06-Lacerations, Cuts, Punctures 02-Fondling 07-Bruises, Welts, Abrasions 03-Sodomy 08-Burns, Scalding 04-Penetration
Systems and Methods, Inc Page 3 of 7 Rev. 03/14/2007 05-Genital Injury 09-Poisoning 06-Contraction of Venereal Disease 10-Suffocation/Drowning 07-Sexual Exploitation 11-FDM/MBP 12-Gunshot
Systems and Methods, Inc Page 4 of 7 Rev. 03/14/2007 Division of Family and Children Services
CHILD ABUSE AND NEGLECT REPORT – FORM 431 (Child Maltreatment Information)
CASE DETERMINATION INFORMATION
Date Investigation Person Completing Completed: Investigation:
MALTREATER INFORMATION
Maltreater Unknown
Marital Status: Race: Never Married Black/African American Married White Separated Asian Widowed American Indian/Alaska Native Divorced Native Hawaiian/Other Pacific Islander Unable to Determine Sex: DOB: Male Female Ethnicity: Hispanic/Latino: Criminal Charges Filed: No Yes Yes No
Systems and Methods, Inc Page 5 of 7 Rev. 03/14/2007 Country of Origin for International Adoption
AFGHANISTAN EGYPT KUWAIT SAUDI ARABIA ALBANIA EL SALVADOR KYRGYZSTAN SENEGAL ALGERIA EQUATORIAL GUINEA LAOS SERBIA AMERICAN SAMOA ERITREA LATVIA SEYCHELLES ANDORRA ESTONIA LEBANON SIERRE LEONE ANGOLA ETHIOPIA LESOTHO SINGAPORE ANGUILLA EUROPA ISLAND LIBERIA SLOVAKIA ANTARCTICA FALKLAND ISLANDS (Islas Malvinas) LIBYA SLOVAKIA ANTIGUA FAROE ISLANDS LIECHTENSTEIN SLOVENIA ARGENTINA FIJI LITHUANIA SOLOMON ISLANDS ARMENIA FINLAND LUXEMBOURG SOMALIA ASHMORE AND CARTIER ISLANDS FRANCE MACAU SOUTH AFRICA AUSTRALIA FRENCH GUIANA MACEDONIA SPAIN AUSTRIA FRENCH POLYNESIA MADAGASCAR (Malagasy SPRATLY ISLANDS AZERBAIJAN FRENCH SOUTHERN AND ANATARCTIC Republic) SRI LANKA (Ceylon) BAHAMAS LANDS MALAWI ST. CHRISTOPHER AND BAHRAIN GABON MALAYSIA NEVIS BAKER ISLAND GAMBIA MALDIVES ST. HELENA BANGLADESH GAZA STRIP MALI ST. LUCIA BARBADOS GEORGIA MALTA ST. PIERRE AND BASSAS DA INDIA GERMANY MAN, ISLE OF MIQUELON BELARUS GERMANY (East) MARTINIQUE ST. VINCENT AND THE BELGIUM GHANA MAURITANIA GRENADINES BELIZE GIBRALTAR MAURITIUS SUDAN BENIN GLORIOSO ISLANDS MAYOTTE SURINAME BERMUDA GREECE MEXICO SVALBARD BHUTAN GREENLAND MIDWAY ISLANDS SWAZILAND BOLIVIA GRENADA MOLDOVA SWEDEN BOSNIA AND HERZEGOVINA GUADELOUPE MONACO SWITZERLAND BOTSWANA GUAM MONGOLIA SYRIA BOUVET ISLAND GUATEMALA MONTENEGRO TAIWAN BRAZIL GUERNSEY MONTSERRAT TAJIKISTAN BRITISH INDIAN OCEAN GUINEA MOROCCO TANZANIA TERRITORY GUINEA - BISSAU MOZAMBIQUE THAILAND BRITISH VIRGIN ISLANDS GUYANA NAMIBIA TOGO BRUNEI HAITI NAURU TOKELAU BULGARIA HEARD ISLAND AND MCDONALD NAVASSA ISLAND TONGA BURKINA FASO (Uvolta) ISLANDS NEPAL TRINIDAD AND TOBAGO BURMA HONDURAS NETHERLANDS TROMELIN ISLAND BURUNDI HONG KONG NETHERLANDS ANTILLES TRUST Territory of the CAMBODIA HOWLAND ISLAND NEW CALEDONIA Pacific Islands CAMEROON HUNGARY NEW ZEALAND TUNISIA CANADA ICELAND NICARAGUA TURKEY CAPE VERDE INDIA NIGER TURKMENISTAN CAYMAN ISLANDS INDONESIA NIGERIA TURKS AND CAICOS CENTRAL AFRICAN REPUBLIC IRAN NIUE ISLANDS CHAD IRAQ NORFOLK ISLAND TUVALU CHILE IRAQ-SAUDI ARABIA, NEUTRAL ZONE NORTHERN MARIANA ISLANDS UGANDA CHINA IRELAND NORWAY UKRAINE CHRISTMAS ISLAND ISRAEL OMAN UNION OF SOVIET CLIPPERTON ISLAND ITALY PAKISTAN - KARACHI SOCIALIST REPUBLICS COCOS (Keeling) ISLANDS IVORY COAST PALMYRA ATOLL UNITED ARAB ERMIRATES COLOMBIA JAMAICA PANAMA UNITED KINGDOM COMORO ISLANDS JAN MAYEN PAPUA NEW GUINEA UNITED STATES OF CONGO JAPAN (also Ryukyu Islands - North) PARACEL ISLANDS AMERICA COOK ISLANDS JARVIS ISLAND PARAGUAY URUGUAY CORAL SEA ISLANDS JERSEY PERU UZEBEKISTAN COSTA RICA JOHNSTON ATOLL PHILLIPINES VANUATU CROATIA JORDAN PITCAIRN ISLANDS VATICAN CITY CUBA JUAN DE NOVA ISLAND POLAND VENEZUELA CYPRUS KAZAKHSTAN PORTUGAL VIETNAM CZECH REPUBLIC KENYA PUERTO RICO WAKE ISLAND DEMOCRACTIC REPUBLIC OF KINGMAN REEF QATAR WALLIS AND FUTUNA CONGO KIRIBATI REUNION WEST BANK DENMARK KOREA, NORTH ROMANIA WESTERN SAMOA DJIBOUTI KOREA, REPUBLIC OF SOUTH RUSSIA WESTERN SHARA DOMINICA KOSOVO RWANDA YEMEN (Aden) DOMINICAN REPUBLIC KURDISTAN SAN MARINO YEMEN (Sanaa) ECUADOR SAO TOME AND PRINCIPE YUGOSLAVIA ZAIRE
Systems and Methods, Inc Page 6 of 7 Rev. 03/14/2007 ZAMBIA ZIMBABWE Unknown
Systems and Methods, Inc Page 7 of 7 Rev. 03/14/2007