Child Protective Service Report, CFS-2090



|Name – Worker |

|Allen Access |

|Name – Reporter |Relationship/Position |

|Denise Goodman |Paternal Grandmother |

|Address (Street, City, State Zip Code) |Telephone |

|2233 Sunset Court |823-7565 |

|Affiliation: |

|Children spend weekends at her home. Children’s father lives with her. |

|Reason for Calling: |

|Concern for Erica and Michael. She feels they are being neglected by their mother |

|Document the Reporter's motivation and source of information, if possible: |

|Direct observation –has the children on weekends and visits regularly. She is upset by the way the mother is acting |

|Reporter’s opinion about needed actions and child’s safety: |

|“I want you to do something to make her act more like a mother, but I don’t think you should take those kids away.” “Well, I don’t know about unsafe, there was |

|dirty dishes all over the kitchen and I wouldn’t be surprised if they weren’t moldy they’d been there so long.” |

|Worker’s opinion of reporter’s credibility: |

|Reporter seems appropriately concerned about the children. Reporter has a somewhat conflictual relationship with mother. |

|Additional comments: |

Reporter Narrative

CHILD PROTECTIVE SERVICE REPORT

|Case Name |Worker Safety Concerns |Report Number |

|Kristina Goodman | |Yes |x |No |xxxxxx |

|Date and Time Report Received |CPS Report Type |County |

|XX:XX XX/XX/XXXX |Primary | |

|Name - Worker |Name - Supervisor |

|Elena Prego |Susan Sup |

|I. |Family Information |

| |Name - Family |Telephone Number - Home |

| |Kristina Goodman |282-1917 |

| |Address - Street |Apt. No. |City / Town |State |Zip Code |

| |816 Elm Street |      |Our Town |WI |55555 |

| |Primary Language: |English |Interpreter Needed: | |Yes |X |No |

| |Directions to House |

| |Off East Main Street |

| |A. |Household Members |

| | | |

| | |Name |

| | |AV |= |Alleged Victim |A |= |Asian or Pacific Islander |

| | |HM |= |Household Member |B |= |Black |

| | |NM |= |Non-Household Member |I |= |American Indian / Alaskan Native |

| | |PN |= |Parent / Parental Role |P |= |Native Hawaiian / Other Pacific Islander |

| | |RN |= |Report Name |U |= |Unable to Determine |

| | | | | |W |= |White |

| | | |

START_DYNAMIC_TABLE=CHILD

| | |Information that the may have American Indian heritage, including names of tribe(s) if known. |

| | |none |

END_DYNAMIC_TABLE=CHILD

| |B. |Parent(s) Not in Home / Other Non-Household Members |

| | |Name |Relationship |Address |Telephone No. |DOB |Gender |Race |

END_DYNAMIC_TABLE=PARENT

| |C. |Alleged Maltreatment |

| | |Alleged Victim |Relationship to Victim |A/N Code |Description |F |

START_DYNAMIC_TABLE=VICTIM

| | |Erica Goodman |Biological Child |      |      |    |

| | |Michael Goodman |Biological Child | | | |

END_DYNAMIC_TABLE=VICTIM

| | | | | |

| | | F |= |Fatality |

| |D. |Location of Incident |

| | |Address - Street |Apt. No. |City / Town |State |Zip Code |

| | |816 Elm Street |      |Our Town |WI |      |

| | |Telephone Number - Home |Telephone Number - Work |Date and Time of Alleged A / N |

| | |282-1917 |      |      |

| |E. |Contacts / Others with Information About Family |

| | |Denise Goodman (grandmother) 823-7565 |

| II. |Narrative |

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| | |Describe alleged maltreatment: current and past; the surrounding circumstances; and the frequency or intervention or services needed for the child. |

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| | |Describe the child(ren)’s injury or conditions as a result of the alleged maltreatment or services needed. |

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| | |Describe the child(ren)’s current location, school/daycare including dismissal time, functioning, including special needs, if any, and highlighting |

| | |current vulnerability. |

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| | |DESCRIBE ANY PRESENT DANGER THREATS, INCLUDING A DESCRIPTION OF POSSIBLE OR LIKELY EMERGENCY (EXIGENT) CIRCUMSTANCES |

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| | |Document relevant information from CPS history, CCAP and Sex Offender Registry-Reverse Address checks (if no relevant information found, document that |

| | |checks were completed). |

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| | |Describe when the alleged maltreater will have acess to the child. |

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| | |Describe any changes in circumstances that may make it difficult ot fulfill CPS responsibilities. |

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| | |Describe presence of domestic violence, if applicable, including the demonstration of power and control and entitlement within the home environment. |

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| | |Describe how the family may respond to intervention by the agency, including the parental protective capacities. |

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| | |THE FOLLOWING SECTION MUST BE COMPLETED FOR ALLEGED MALTREATMENT BY PRIMARY CAREGIVER OR PARENTAL CONTRIBUTION TO THE MALTREATMENT: |

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| | |Describe the parents or adults in the parental role: current location, functioning, and parenting practices and views of child(ren). |

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| | |Describe the family functioning, strengths and current stressors. |

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| | |DESCRIBE THE POSSIBLE OR LIKELY IMPENDING THREATS TO CHILD SAFETY. |

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| | |Document the name of the alleged maltreater and relationship to child. |

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|III. |Agency Response |

| |A. |Supervisor Screening Decision |

| | |Decision |Date / Time Decision was Made |

| | |      |      |

| | |Response Time |Reason |

| | |      |      |

| | |Explain |

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| |B. | Yes No Law Enforcement Notified |

| | | Yes No After Hours Report |

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|IV. |Signatures |

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| | SIGNATURE - Worker | |Date Signed | |

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| |SIGNATURE - Supervisor | |Date Signed | |

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