Cps 32 child fatality serious injury report
- 1. County Name __________________Date of Child Death __________ Date of Serious Injury ___________________ I. IDENTIFYING INFORMATION First Name Middle Name Last Name DOB Ethnicity/Sex A. Child: _____________________________________________________________________________________ B. Names of Parents: Mother: __________________________________________DOB: ____________In Home?_____________________ Father: __________________________________________DOB: ____________In Home?_____________________ C. Caretaker, if different from parent(s) Name: ___________________________________________Relationship____________________________________ _______________________________________________________________________________________________ D. Who had legal custody of child at time of the death/serious injury? __________________________________ E. Other people living in home at time of death/injury: If child has minor siblings who are not living in the home, please list name, age and whereabouts in III. E, page 2. Add another page, if necessary. Name Age Rel.to Child If Child, Current Whereabouts _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _____ II. DEATH/SERIOUS INJURY SUMMARY A. Date reported to DFCS: _____________ Cause of death/serious injury, known or suspected, at time of report: _________________________________________________________________________________________ Circumstances of fatality or serious injury (what happened): _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ (1) ___Abuse suspected? (2) ___Neglect suspected? (3) ___Abuse and neglect? (4)___CA/N not suspected ? If 1, 2, or 3 checked give name of alleged maltreater: __________________________________________________ Law enforcement notified? YES___ NO___ Arrest made? YES___ NO___ Autopsy Completed? YES__NO__ B. Other agencies involved with assessment of fatality/serious injury: __________________________________ _______________________________________________________________________________________________ C. Significant medical information (pre-existing medical conditions; current condition if injured, Page 1 CPS_32 Child Fatality/Serious Injury Report (Revised 09/06) DIVISION OF FAMILY AND CHILDREN SERVICES CHILD DEATH/SERIOUS INJURY REPORT
- 2. etc.)____________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ III. COUNTY DFCS HISTORY (Check appropriate areas) A. Open Service Cases - Current History Comments ___ CPS opened before child’s death/serious injury? Date opened ________ ___ CPS opened because of child’s death/serious injury? Date opened ________ ___ Prevention opened before child’s death/serious injury? Date opened ________ ___ PLC opened before child’s death/serious injury? Date opened ________ ___ PLC opened because of child’s death/serious injury? Date opened ________ ___ Open Adoption case? ___ Other open Service case? Type ________________ Date ________ B. Closed Service Cases - Past History ___ Screened out CPS? Date screened out _________ ___ Closed CPS investigation? Date of referral_________ Disposition __________Date closed________ ___ Closed CPS ongoing? Date opened _________Date closed_________ ___ Closed Prevention? Date opened _________Date closed_________ ___ Closed PLC? Date opened _________Date closed_________ ___ Closed Adoption? Date finalized__________ ___ Other Closed Service? Type _________________________ Date _________ C. Case Summary: (What are the specifics of DFCS involvement with this family? Include your knowledge of other counties involved with the family.) _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ D. Results of risk assessment of children remaining in the home_______________________________________ _______________________________________________________________________________________________ E.Other Information (NOTE: Forward additional information within 10 days of receiving) _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Form Completed By: _____________________________Date: _____________________________ Page 2 CPS_32 Child Fatality/Serious Injury Report (Revised 09/06)
- 3. County Contact Person: ___________________________ Phone Number: ________________________________ I have taken possession of all original service case records: County Director’s/Designee Signature: ______________________________________Date: ___________________ Page 3 CPS_32 Child Fatality/Serious Injury Report (Revised 09/06)