Child Care & Child Welfare Forms

Child Care and Child Welfare Forms

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Child Care Forms & Publications

Form No.	Date	Title
N/A	04/06	Family Child Care Policy Sample - Word
N/A	04/06	Family Child Care Policy Sample - PDF
CFS-52	09/05	Vehicle Safety Inspection
CFS-53	12/04	Staff Record - Child Care Centers
CFS-53A	12/04	Staff Continuing Education Record - Child Care Centers
CFS-54	12/04	Staff Health Report - Child Care Provider
CFS-55	12/04	Accident Report - Child Care Centers (PDF)
CFS-55	12/04	Accident Report - Child Care Centers (Word)
CFS-56	01/05	Transportation Permission - Child Care Centers
CFS-57	12/04	Informed Consent for Observation or Testing by an Outside Agency - Child Care Centers
CFS-58	12/04	Field Trip or Other Activity Notification/Permission - Child Care Centers
CFS-58R	12/04	ИЗВЕЩЕНИЕ / РАЗРЕШЕНИЕ НА ЭКСКУРСИЮ ИЛИ ДРУГОЕ МЕРОПРИЯТИЕ – ЦЕНТРЫ ПО УХОДУ ЗА ДЕТЬМИ
CFS-58S	12/04	Authorización/Notificación De Excursión Escolar U Otra Actividad De Guarderias
CFS-59	07/05	Authorization to Administer Medication - Child Care Centers
CFS-59R	07/05	РАЗРЕШЕНИЕ НА ПРИЕМ (ВВЕДЕНИЕ) ЛЕКАРСТВА – ЦЕНТРЫ ПО УХОДУ ЗА ДЕТЬМИ
CFS-59S	07/05	Autorización Para Administrar Medicamentos - Centros De Cuidado Infantil
CFS-60	01/06	Child Health Report - Child Care Centers
CFS-60R	02/08	ОТЧЕТ О ЗДОРОВЬЕ РЕБЕНКА – ЦЕНТРЫ ПО УХОДУ ЗА ДЕТЬМИ
CFS-60S	01/06	Informe Médico Del Niño - Guarderias
CFS-61	02/05	Intake for Child Under 2 Years - Child Care Centers
CFS-61R	02/08	ИНФОРМАЦИЯ, НЕОБХОДИМАЯ ДЛЯ ПРИЕМА РЕБЕНКА ДО 2 ЛЕТ – ЦЕНТРЫ ПО УХОДУ ЗА ДЕТЬМИ
CFS-61S	02/05	Admision Para Ninos Menores de 2 Anos - Guarderias
CFS-62	01/05	Child Care Enrollment
CFS-62R	01/05	ЗАЧИСЛЕНИЕ В ЦЕНТРЫ ПО УХОДУ ЗА ДЕТЬМИ
CFS-62S	01/05	Inscripción En El Servicio De Cuidado Infantil (PDF)
CFS-62S	01/05	Inscripción En El Servicio De Cuidado Infantil (Word)
CFS-63	04/07	Licensing Checklist - Group Child Care Centers HFS 46
HFS-64A	02/08	Background Information Disclosure
HFS-64AH	02/08	LUS QHIA UA TXOG DAIM NTAWV QHIA TAWM TXOG KEEB KWM
HFS-64AS	02/05	Instrucciones Para Divulgar Informacion de Antecedentes
CFS-65	01/05	License Application - Group Child Care Centers
CFS-67	01/05	License Application - Family Child Care Centers
CFS-69	10/05	Licensing Checklist - Family Child Care Centers HFS 45
CFS-70	04/07	Licensing Checklist - Day Camps for Children
CFS-78	09/07	Child Care Staff-to-Child Ratio Worksheet Group Child Care Centers
PFS-101	01/06	It Shouldn't Hurt to be a Child
CFS-104	07/07	Alternate Arrival / Release Agreement - Child Care Centers
CFS-297	09/05	Request for Exception
CFS-460	01/05	Fire Safety and Emergency Response Documentation - Family Child Care Centers
CFS-497	11/04	Directory Listing / Mailing Labels Order
CFS-543	01/05	Fire Safety and Emergency Response Documentation - Group Child Care Centers
CFS-782	05/05	License Application - Day Camps for Children
CFS-1675	01/05	Child Record Checklist - Child Care Centers
CFS-1675A	12/04	Staff Record Checklist - Group Child Care Centers
CFS-2022	12/07	Child Care Inquiry Packet Request
CFS-2026	12/05	Staff Orientation Checklist - Group Child Care Centers
CFS-2027	01/05	Volunteer Training Confirmation - Group Child Care Centers
CFS-2048	02/05	Policy Checklist - Group Child Care Centers
CFS-2114	09/05	Continuing Education Record - Independent Reading / Video Viewing
CFS-2241	01/06	Initial Licensing Checklist - Family Child Care Centers
CFS-2242	01/05	Initial Licensing Checklist - Group Child Care Centers
CFS-2255	04/06	Staff Orientation Checklist - Family Child Care Centers
CFS-2261	11/03	Caregiver Background Checks Substantially Related Investigation Report (PDF)
CFS-2261	11/03	Caregiver Background Checks Substantially Related Investigation Report (Word)
CFS-2344	10/06	Building Inspection Report - Child Care Centers
CFS-2345	07/05	Health History and Emergency Care Plan
CFS-2345S	07/05	Plan Historial De Salud Y Cuidado De Emergencia
CFS-2356	03/06	Policy Checklist - Family Child Care Centers
PFS-3038	08/07	Instructions for Obtaining Forms - Group & Family Child Care Centers
PFS-3064	01/05	Requirements for Caregiver Background Checks for Child Care Centers
DPH-4020L	02/08	Student Immunization Record
DPH-4020S	02/08	Registro De Vacunas Del Estudiante
PFS-4085	07/07	Licensing Collaborative Child Care Programs
PFS-4088	06/05	Use of 10+ Passenger Vans To Transport Children To and From Schools
PFS-4091	02/05	Entry-Level Non-Credit Courses for Licensed Child Care
DPH-4192	02/08	Day Care Immunization Record
DPH-4192S	07/03	Registro De Inmunizaciones Para Guardería Infantil

Child Welfare Forms & Publications

Form No.	Date	Title
CFS-52	09/05	Vehicle Safety Inspection
HFS-64A	02/08	Background Information Disclosure
HFS-64AH	02/08	LUS QHIA UA TXOG DAIM NTAWV QHIA TAWM TXOG KEEB KWM
HFS-64AS	02/05	Instrucciones Para Divulgar Informacion de Antecedentes
CFS-74	10/04	Adoption Assistance Agreement (PDF)
CFS-74	10/04	Adoption Assistance Agreement (Word)
CFS-100A	07/06	ICPC Placement Request (PDF)
CFS-100A	07/06	ICPC Placement Request (Word)
CFS-100B	07/06	ICPC Report on Child's Placement Date or Change of Placement (PDF)
CFS-100B	07/06	ICPC Report on Child's Placement Date or Change of Placement (Word)
PFS-101	01/06	It Shouldn't Hurt to be a Child
CFS-107	02/03	Foster Home Agreement Child Placed In Out-of-Home Care by Agency
CFS-116	02/00	Foster Parent Insurance Program Claim of Loss or Damage
CFS-117	02/00	Foster Parent Insurance Program Verification of Claims
CFS-136	05/01	Formal Adoption Application
CFS-142	01/02	Affidavit
CFS-251	03/05	License Application - Residential Care Centers for Children and Youth
EXS-263	03/01	Rehabilitation Review Application and Instructions
CFS-297	09/05	Request for Exception
CFS-353	04/07	Sanitation Checklist - Residential Care Centers
CFS-354	09/05	Licensing Checklist - Residential Care Centers
CFS-357	01/06	Fire Safety Inspection - Residential Care Centers
CFS-358	11/06	Licensing Checklist - Group Foster Homes for Children
CFS-361	12/07	Licensing Checklist - Shelter Care Facilities
CFS-362	04/07	Licensing Checklist - Child Placing Agencies
CFS-367	03/01	Community Advisory Committee Documentation
CFS-369	09/07	Personnel Record Checklist - Child Placing Agencies
CFS-375	05/06	License Application - Group Foster Homes
CFS-379	09/05	Child Record Checklist - Group Foster Homes
CFS-380	05/04	Child Placing Agency Foster Child Record Checklist
CFS-381	05/06	Foster Home Record Checklist - Child Placing Agencies
CFS-383	09/05	Personnel Record Checklist - Group Foster Homes
CFS-384	09/05	Staff Health Report - Child Welfare Facilities
CFS-395	08/05	License Application - Child Placing Agency
PDE-470A	08/06	Rights of Minors in Inpatient Community Mental Health Facilities (PDF)
PDE-470A	08/06	Rights of Minors in Inpatient Community Mental Health Facilities (Word)
CFS-497	11/03	Directory Listing / Mailing Labels Order
CFS-786	03/05	License Application - Shelter Care Facility
CFS-787	06/02	Child Foster Care Licensing Checklist
CFS-834	01/08	Foster Care Uniform Rate Setting (PDF)
CFS-834	01/08	Foster Care Uniform Rate Setting (Word)
CFS-847	11/07	Application to DHFS Exceptions Panel for Exception to Ch. HFS 56 or HFS 38
CFS-872A	01/02	Information for Foster Parents - Part A
CFS-872B	08/02	Information for Foster Parents - Part B
CFS-909	09/05	Fire Safety Inspection - Group Foster Homes
DMT-974	08/05	Instructions for Completing Budget/Claim Forms to Recover Federal Foster Care Funds for Residential Care Centers for Children and Group Foster Homes for Children
DMT-975	08/05	Federal Reimbursement Budget - Schedule A Residential Care Centers for Children/Group Foster Homes for Children
DMT-977	08/05	Operating Statement - Schedule B Residential Care Centers for Children/Group Foster Homes for Children
DMT-978	08/05	Rate Computation Report - Schedule C
DMT-979	08/05	Physical Plant Utilization Square Footage Allocation - Schedule D Group Foster Homes for Children
DMT-980	08/05	Physical Plant Utilization Square Footage Allocation - Schedule D Residential Care Centers for Children
DMT-981	08/05	Allocation of Expenses by Function - Schedule E Residential Care Centers for Children
DMT-982	08/05	Allocation of Expenses by Function - Schedule E Group Foster Homes for Children
CFS-997	03/01	Medical Services Consent
CFS-1590	04/08	Voluntary Placement Agreement
JD-1710	08/06	Temporary Physical Custody Request
CFS-2020	10/03	Residential Care Center Type 2 Designation Request
CFS-2029	11/07	Exceptions Panel Placement of a Non-Treatment Child
CFS-2091	12/05	Child's Death, Serious Injury or Egregious Incident Notification (PDF)
CFS-2091	06/06	Child's Death, Serious Injury or Egregious Incident Notification (Word)
CFS-2114	09/05	Continuing Education Record - Independent Reading / Video Viewing
CFS-2139	10/07	Resident Record Checklist - Residential Care Centers for Children and Youth
CFS-2140	03/04	Residential Care Center General Personnel Record Checklist
CFS-2142	09/05	Staff Continuing Education and Training Record Child Welfare Programs
CFS-2146	04/06	Serious Incident Report (PDF)
CFS-2146	04/06	Serious Incident Report (Word)
CFS-2149	11/07	Exceptions Panel Second License Application
CFS-2155	11/07	Adoptive Placement Checklist - Child Placing Agency International
CFS-2168	09/00	Residential Care Center Policy / Procedure Checklist (PDF)
CFS-2168	09/00	Residential Care Center Policy / Procedure Checklist (Word)
CFS-2172	09/00	Residential Care Center Child Abuse and Neglect Reporting and Confidentiality Responsibilities
CFS-2183	02/05	Residential Care Center Statutorily Reportable Death (PDF)
CFS-2183	02/05	Residential Care Center Statutorily Reportable Death (Word)
CFS-2186	12/05	Notice to Foster Parents Regarding Confidentiality of Records
CFS-2187	03/04	Foster Home / Treatment Foster Home Licensure Notification
CFS-2189	03/04	Out-of-Home Placement Notification or Recommended Placement Notification
CFS-2191	07/04	HFS 12 Negative Action Notice
CFS-2198	02/05	Foster Parent Insurance Program Damage Claim Checklist
CFS-2259	11/07	Adoptive Placement Checklist - Child Placing Agency - Domestic
CFS-2261	11/03	Caregiver Background Checks Substantially Related Investigation Report (PDF)
CFS-2261	11/03	Caregiver Background Checks Substantially Related Investigation Report (Word)
CFS-2338	09/05	Medication Administration Record - Group Foster Homes for Children
CFS-2343	01/06	Shift-Staffed Treatment Foster Home Exception Application Checklist (PDF)
CFS-2343	01/06	Shift-Staffed Treatment Foster Home Exception Application Checklist (Word)
CFS-2378	10/05	Policy/Procedure Checklist - Group Foster Homes for Children
CFS-2379	09/05	Medical Services Consent - Child Welfare Facilities
CFS-2380	09/05	Staff / Volunteer Orientation Documentation - Group Foster Homes
CFS-2381	09/05	Resident Orientation Documentation - Group Foster Homes
CFS-2382A	09/05	Intake Information - Group Foster Home Resident (PDF)
CFS-2382A	09/05	Intake Information - Group Foster Home Resident (Word)
CFS-2382B	10/05	Intake Information - Group Foster Home Resident Under 6 Years of Age (PDF)
CFS-2382B	10/05	Intake Information - Group Foster Home Resident Under 6 Years of Age (Word)
CFS-2383	02/06	Fire Safety and Emergency Response Documentation - Residential Care Centers for Children and Youth
CFS-2384	09/05	Fire Safety and Emergency Response Documentation - Group Foster Homes
CFS-2385	04/06	Fire Safety and Emergency Response Documentation - Shelter Care Facility
CFS-2386	12/06	Foster Home Information for WiSACWIS (PDF)
CFS-2386	12/06	Foster Home Information for WiSACWIS (Word)
CFS-2389	02/06	Child Record - Shelter Care Facilities (PDF)
CFS-2389	02/06	Child Record - Shelter Care Facilities (Word)
CFS-2414	12/07	Child Record Checklist - Shelter Care Facilities
PFS-4067	06/06	Instructions for Obtaining Forms - Residential Care Centers for Children & Youth
PFS-4088	06/05	Use of 10+ Passenger Vans To Transport Children To and From Schools
PFS-4089	01/05	HFS 54 - Child Placing Agencies - Annotated
PFS-4097	04/06	Instructions for Ordering Forms - Child Placing Agency
PFS-4098	09/05	Instructions for Ordering Forms - Shelter Care & Group Foster Homes
PFS-4100	02/06	Personnel Requirements - Group Foster Homes for Children