Request Case File Format .ky.gov



LEFT SIDE

|Top Section/Tab |Middle section/Tab |Bottom section/Tab | |

|SERVICES |ON-GOING ASSESMENT & CASE PLAN |ADMINISTRATION |ADMINISTRATION (cont.) |

|Service Recordings |CPS CQA, Continuous Quality Assessment Form or ADT |Foster Care Review Board (FCRB) Requests |DSS-1259 Benefits Action Transmittal |

|Transfer Summary |APS CQA Continuous Quality Assessment Form or ADT |Worker Letters (outgoing) |DSS-1260 Title IV-E Child Support Form |

|Case Transfer form |P&P-1282 Family Case Plan (including the OOHC section) |DCBS-1 Informed Consent & Release of Information Records |DCBS-1261 Title IV-E Action Sheet |

|Closing Summary |Prevention Plan |DCBS-1A Informed Consent & Release of Information Records Supplement |DSS-1262 Title IV-E Eligibility/Reimbursability Summary |

|Aftercare Plan |Visitation Contracts |DPP- 886 PCC Client Inter-Agency Referral Form |DCBS-1265 Redetermination Status Report |

| |Signature Sheets |DPP-886A Application for Referral and Needs Assessment |DCBS-1273 Establishing a CFC Trust Fund |

| |DPP-293 Adult Personal Development Plan |DSS-892 Daily Routine for Preschool Age Children |DCBS-1274 Change in Payee |

| |DPP-294 Individual Adult Safety Plan |DSS-893 Daily Routine/School Age Child |DPP-1279 Information for OOHC Placements |

| |Concurrent planning Forms/Matrix (Remember to |Child Behavior Checklist (Achenbach) |DPP-1299 Referral for Emergency Weatherization |

| |chronologically file with the dated assessment just |Reiss Scales for Children’s Dual Diagnosis & Scales for Independent Behavior |Notice of Child Fatality/Near Fatality |

| |immediately before the case plan). |All Children Review Program (CRP) forms |Fatality/Near Fatality 60 Day Internal Review Template |

| |Homemaker Approval |IV-E Preventative Assistance |KC-01 Kinship Care Program Statement of Rights and Responsibilities |

| |Homemaker Contract |Clothing Letter |KC-02 Kinship Care Respite Request Form |

| |DPP-1276 Relative Home Evaluation-Outline |Other Financial Forms |KC-02A Kinship Care Respite Services Receipt Form |

| | |Financial related correspondence (i.e. medical bills, KHSA emergency fund) |KIM-78KC Kinship Care Financial Assistance Application |

| | |DCBS-173 Benefits Change Notice |Investigator’s Checklist for Kinship Care |

| | | |Ongoing Worker’s Checklist for Kinship Care |

| | | |Kinship Care Checklist |

| | | |Region Log for Kinship Care Start Up |

| | | |Relative Resource Information Sheet |

| | | |Transportation-Non-committed Client Approval |

| | | |LIHEAP Preventative |

| | | |MA Cards |

| | | |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 Log |Drug Screens |Courts Orders, Reports & Calendars Correspondence to Judges/Courts from CHFS |CPS Multiple Response Matrix |

|DPP-106A Authorization for Routine Health Care and |DCC-86 Referral for Child Care Assistance |Petitions |Protective Services Investigative Findings Adult Abuse, Neglect, or |

|Authorization for Non-Routine Health Care |PAFS 628 Exchange of Information |All AOC Forms |Exploitation |

|DPP-106B Initial Physical and Behavioral Health History |HIPAA forms |Court Ordered Home Evaluations |Notification of Protective Services Investigative Findings Adult |

|DPP-106C Child Medical History and Annual Physical Exam |DCC-85 Authorization for Child Care Assistance |ECO, EPO, and DVO |Abuse, Neglect, or Exploitation |

|DPP-106D Medical Appointment |Educational/Vocational Related Material |Affidavits |Initial Investigative CQA or ADT |

|DPP-106E Dental Care |DPP-103 Application for Tuition Assistance for Youth Committed|All judicial orders |DPP-152 CPS Substantiated Investigation Notification Letter |

|DPP-106F Visual Screening |to CHFS-DCBS |All correspondence to and from the court |DPP-152A CPS Unsubstantiated Investigation Notification Letter |

|DPP-106G Mental Health Services |Educational Assessment Referral Form |All absent parent search documentation |DPP-153 CPS FINSA Notification Letter |

|DPP-106H Medication Administration Form |Educational Assessment Referral Letter |All forms related to establishment of paternity |DPP-153A CPS Family Not In Need of Services Notification Letter |

|DPP-106I Methamphetamine Exposure Medical Administration |Educational Assessment Thirty Day Follow-up Referral Letter |DPP-111A Foster Home Contract Supplement |JC3 |

|Record |Independent Living Information |DPP-114 Level of Care Schedule |Any investigation photos |

|DPP-106 |Impact Plus Addendum |DSS-158 Petition-Voluntary Termination of Parental Rights |Intake/Investigation related correspondence |

|DPP-1268 Medical Information for Newborn Infants Form |Impact Plus Request for Services |DSS-160 Statement of Representatives of the Cabinet for Families & Children |DPP-154 Service Appeal Request |

|DSS-1293 Rehab Approval Form |Impact Plus (correspondence) |DSS-161 Request for Involuntary Termination of Parental Rights |DPP-154A Notice of Intended Action |

|DSS-1294 Rehab Monthly Service Report |Impact Request for services (correspondence) |DSS-167 Consent to Voluntary Commitment |DPP-155 CAPTA Appeal |

|CHFS Out-of-Home Care Service Plan for Physical Health |Independent Living Referral Form |DSS-177 Report of Filing of Petition For Involuntary TPR |DPP-156 Central Registry Check |

|Client Photographs (Non-investigative) |Insurance Information |DSS-215 Consent to Adoption |DPP-157 Child Abuse or Neglect Check |

|Social Security Cards (copies) |RIAC Request |DSS-1266 Affidavits of Reasonable Efforts |DPP-1300 Service Complaints Monthly Report |

|Birth Certificates (copies) |DPP-130 Daily Record of Events (DROE) |Absent Parent Search Form |Documentation from professionals/ collaterals pertinent to the |

|VS37 Application for Birth Certificates |Parenting class material (correspondence) |Criminal Record Check |investigation |

|DPP-117 Verification of Marriage/Divorce |DPP-1020 Safety Net Assessment |Investigation Report Concerning Custodial Arrangements for the Child | |

|Letters from service providers, including therapists |DPP-1021 Safety Net Verification form |Confidentiality Report to Circuit Court on the Petition to Adopt a Child | |

|Psychological Evaluations |DPP-1022 Safety Net Report |Predispositional Investigation Report | |

|Internal/External Referrals |DCBS AC-1 Transmittal Memo Presentation Summary |Expiration of Temporary Custody Order | |

|External Service Provider Information |Presentation Summary and Attachments | | |

| |Confirmation Notice for DNR | | |

*Note: Each section should be in chronological order with most recent dates at top.

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