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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