Child Custody Sample Questions

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					                                                            Placement Stability Project
                                                        Placements/Disruptions Information

       A           B   C       D       E       F            G           H            I          J           K             L            M           N

                                                                                                        Specific     Services      Name of
     CHILD    CHILD                 Child                       Number                                                                      Average #
                                            Plcmt.     PLCMT.             By Days            By Mts.   Reason for   Provided to     Foster
     LAST     FIRST    Age   County Plcmt.                      Days in                                                                      Days in
                                           Begin Date END DATE             in Care           in Care   Placement      Prevent        Care
     NAME     NAME                     #                       each Plcmt                                                                    Plcmts.
                                                                                                          End        Disruption    Provider
1
                                                                                                         Child       Disruption
2    Sample   Name                     1    2/15/2005   2/28/2005       13          13         0.4      Behavior      Staffing     B. Smith
                                                                                                         Over
 3   Sample   Name                     2    2/28/2005  6/3/2005         95         108         3.6      Capacity                     A. Doe
 4   Sample   Name                     3     6/3/2005 12/22/2005       202         310        10.3      Reunified                    Parents
 5                                                                                 144                                                             144
 6    New      Child                   1                                 *With each new child entry, formulas for Colums H, I & J must be re-entered.
 7    New      Child                   2
 8    New      Child                   3
 9    New      Child                   4
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      11/22/2010                                                                                                                                  1
                                                                                      Child Placement Demographics


            A                 B          C          D     E      F      G           H                I               J          K             L             M           N             O              P             Q
                                                                                                                            #                         F.P.                      Child                         Supports
                                                                                                                                                                   Child                       Case notes
                                                                                             Specific Abuse                 Placements                provided                  Disabilities                  provided to
                       Child First                                                                                                       Current type              prepared for                reveal type
     Child Last Name                 County   DOB       Age   Race   Gender   Removal Date   which brought      Case Goal   during                    with child                on Child                      child and/or
                       Name                                                                                                              placement                 plcmt.                      disabilities
                                                                                             child into custody             current                   info. at                  Info.                         caregiver re
                                                                                                                                                                   Change?                     Yes/No
                                                                                                                            removal                   plcmt.                    Summary?                      needs?
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      11/22/2010                                                                                                                                                                                                             2
                                                                                                              Child Placement Demographics


          R            S             T            U            V            W              X              Y             Z
                                                           Frequency                                 F.P.
                                 Child visits Child visits             Frequency     Chronos
                  If child not                             of case                                   involvement   Further
     Child placed                regular      regular                  of case       reflect
                  w/sibs, are                              manager                                   with birth    Review
     with                        w/Mother, or w/Father, or             manager       details of
                  regular visits                           visits to                                 parent or     Needed
     siblings?                   as court     as court                 visits with   child's well-
                  occurring?                               caregiver                                 other         Yes/No
                                 ordered?     ordered?                 parents       being?
1                                                          home                                      caregiver?
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      11/22/2010                                                                                                                             3
                                                                                        Foster Parent Demographics

  Foster
                                                                                                                                                                        # Foster     Adults in
Family:                                                          Father     Mother                       Socio                                                                                       Birth
                Open /      County of                                                   F.P. Marital                                            Employmt.   Employmt    children     the home
       Last                             Father DOB Mother DOB     Race       Race                      Economic   Military   Religion   Other                                                     children in
              Closed File   Jurisdictn.                                                    Status                                                 Father     Mother    currently in (other than
Name, First                                                     Ethnicity   Ethnicity                    Status                                                                                    the home
                                                                                                                                                                          home        parents)
   Name




11/22/2010                                                                                                                                                                                                      4
                                                                                          Foster Parent Demographics

                                                        Is family                                                                                                                   Date of       Does
                                                                                                       Has family                 Attend    Type Child    Family        Other                               Family
 How was                    Date Initial    Current      now or     Family                   MAPP                                                                                 request for   closure
             Date Initial                                                       Date First              received    Member of    support    Requestd     satisfactn   informatn                            willing to
  family                     License       licensed    ever been     under                  Completn                                                                              closure and code match
               Inquiry                                                         Child Plcmt.               other     F.P. Assn.    group       During     survey on       and                              be permant
 recruited                   Approval       capacity      over      capacity                  Date                                                                                  closure    reason for
                                                                                                         training                meetings    Licensing     record      comment                              family?
                                                         capacity                                                                                                                     code      closure/




11/22/2010                                                                                                                                                                                                              5
                                                                       Foster Parent Demographics

 Positive               # Children
 attitude     Home      that have
                                     Follow-up   Services   Services
 toward       study        been
                                     Questions   Requestd   Provided
  birth      complete    placed in
 parent?                this home




11/22/2010                                                                                          6
                                       Placement Stability Project
       Targeted Recruitment by ZIP Codes - Number of Foster Homes, Beds, Children's Initial Removal

             A                      B                      C                     D

       Foster Homes/Initial Child Removals by ZIP CODES During
                                Past Year
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                            # Childrens Initial                         Number of Licensed
                                                  # Foster Homes in
     AREA ZIP CODE #s     Removal by ZIP Code                          Beds Available by ZIP
                                                   ZIP CODE Area
                                   Area                                    CODE Area
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11/22/2010                                                                                            7
                                       Placement Stability Project
       Targeted Recruitment by ZIP Codes - Number of Foster Homes, Beds, Children's Initial Removal

             E




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11/22/2010                                                                                            8

				
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