Tennessee
|[pic] |Tennessee Department of Children’s Services |
| |Juvenile Justice Case Transfer Checklist |
Note: This form is uploaded to the case file.
|Date |
|Youth’s Name | |Date of Birth | |
|Race | |Case Type: | |
|County of Jurisdiction | |Judge | |
|The Following Items are Updated and Enclosed in the File |
|Social Security Card | Yes No NA |Medical Records | Yes No NA |
|Court Orders and Petitions | Yes No NA |Rules of Probation or Aftercare with | Yes No NA |
| | |Signatures | |
|Schools Records | Yes No NA |Immunization Record | Yes No NA |
|Education Passport | Yes No NA |CANS Assessment | Yes No NA |
|Birth Certificate | Yes No NA |Visitation Record or Information | Yes No NA |
|Permanency Plan | Yes No NA |TennCare Card | Yes No NA |
|Notification of Change of Circumstance | Yes No NA |
|Other | |
|The Following has been Documented or Updated in TFACTS to Reflect the Most Current Information |
|Case Summary | Yes No NA |Supervision Level | Yes No NA |
|Child & Family Information | Yes No NA |Placement Icon | Yes No NA |
|Education Icon | Yes No NA |Reviews/Hearing Icon | Yes No NA |
|Family Permanency Plan Icon reflects | Yes No NA |Medical Icon to reflect most recent | Yes No NA |
|current Plan Goal, and Ratification | |EPSD&T Medical/Dental | |
|Face-to-Face documentation | Yes No NA |Other | |
| | | |
|Sending Supervisor Signature | |Case Transfer Effective Date |
|Note: signature denotes you have reviewed the case file prior to transfer | | |
| | | |
|Records Received By (Name and Title) | |Date Received |
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