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 |
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| | |Response Time |Reason |
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| | |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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