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Children's Residential Facility

Forms & Publications

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Form No. Date Title
DCF-F-CFS52 12/08 Vehicle Safety Inspection
HFS-64A (F82064) 01/09 Background Information Disclosure
HFS-64AH (F82064H) 01/09 LUS QHIA UA TXOG DAIM NTAWV QHIA TAWM TXOG KEEB KWM
HFS-64AS (F82064S) 01/09 Instrucciones Para Divulgar Informacion de Antecedentes
DCF-F-CFS74 04/09 Adoption Assistance Agreement (PDF)
DCF-F-CFS74 04/09 Adoption Assistance Agreement (Word)
DCF-F-CFS100A 07/09 ICPC Placement Request (PDF)
DCF-F-CFS100A 07/09 ICPC Placement Request (Word)
DCF-F-CFS100B 07/09 ICPC Report on Child's Placement Date or Change of Placement (PDF)
DCF-F-CFS100B 07/09 ICPC Report on Child's Placement Date or Change of Placement (Word)
DCF-P-PFS101 08/09 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
DCF-F-CFS142 01/09 Affidavit
CFS-251 03/05 License Application - Residential Care Centers for Children and Youth
EXS-263 (F83263) 07/08 Rehabilitation Review Application and Instructions
DCF-F-CFS297-E 10/09 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 04/08 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 11/08 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
P-20470A 12/08 Rights of Minors in Inpatient Community Mental Health Facilities (PDF)
CFS-497 11/04 Directory Listing / Mailing Labels Order
CFS-786 03/05 License Application - Shelter Care Facility
CFS-787 06/02 Child Foster Care Licensing Checklist
DCF-F-CFS834 01/09 Foster Care Uniform Rate Setting (PDF)
DCF-F-CFS834 01/09 Foster Care Uniform Rate Setting (Word)
DCF-F-CFS847 10/09 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
DCF-F-2435 (DMT-974) 03/09 Instructions for Completing Budget/Claim Forms to Recover Federal Foster Care Funds for Residential Care Centers for Children and Group Foster Homes for Children
DCF-F-2447 (DMT-975) 03/09 Federal Reimbursement Budget - Schedule A Residential Care Centers for Children/Group Foster Homes for Children
DCF-F-2446 (DMT-977) 03/09 Operating Statement - Schedule B Residential Care Centers for Children/Group Foster Homes for Children
DCF-F-2450 (DMT-978) 03/09 Rate Computation Report - Schedule C
DCF-F-2449 (DMT-979) 03/09 Physical Plant Utilization Square Footage Allocation - Schedule D Group Foster Homes for Children
DCF-F-2444 (DMT-980) 03/09 Physical Plant Utilization Square Footage Allocation - Schedule D Residential Care Centers for Children
DCF-F-2445 (DMT-981) 03/09 Allocation of Expenses by Function - Schedule E Residential Care Centers for Children
DCF-F-2448 (DMT-982) 03/09 Allocation of Expenses by Function - Schedule E Group Foster Homes for Children
CFS-787 06/02 Child Foster Care Licensing Checklist
CFS-997 03/01 Medical Services Consent
DCF-F-CFS1590 04/08 Voluntary Placement Agreement
JD-1710 08/06 Temporary Physical Custody Request
CFS-2020 10/03 Residential Care Center Type 2 Designation Request
DCF-F-CFS2022 07/09 Ordering Information - Inquiry Packets
CFS-2029 11/07 Exceptions Panel Placement of a Non-Treatment Child
DCF-F-CFS2091 03/09 Child's Death, Serious Injury or Egregious Incident Notification (PDF)
DCF-F-CFS2091 03/09 Child's Death, Serious Injury or Egregious Incident Notification (Word)
DCF-F-CFS2114 03/09 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)
DCF-F-CFS2149 10/09 Exceptions Panel Second License Application
CFS-2155 11/08 Adoptive Placement Checklist - Child Placing Agency International
DCF-F-CFS2168 07/09 Residential Care Center Policy / Procedure Checklist (PDF)
DCF-F-CFS2168 07/09 Residential Care Center Policy / Procedure Checklist (Word)
CFS-2172 09/00 Residential Care Center Child Abuse and Neglect Reporting and Confidentiality Responsibilities
DCF-F-CFS2183 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
DCF-F-CFS2191 02/09 DHS 12 Negative Action Notice
CFS-2198 02/05 Foster Parent Insurance Program Damage Claim Checklist
CFS-2259 11/08 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
DCF-F-CFS2386 05/09 Foster Home Information for WiSACWIS (PDF)
DCF-F-CFS2386 05/09 Foster Home Information for WiSACWIS (Word)
CFS-2389 04/08 Child Record - Shelter Care Facilities (PDF)
CFS-2389 04/08 Child Record - Shelter Care Facilities (Word)
CFS-2399 04/08 Personnel Record Checklist - Shelter Care Facilities
CFS-2414 12/07 Child Record Checklist - Shelter Care Facilities
CFS-2430 10/08 Assessment, Treatment Plan and Discharge Plan - Group Foster Homes for Children (PDF)
CFS-2430 10/08 Assessment, Treatment Plan and Discharge Plan - Group Foster Homes for Children (Word)
DCF-F-2440 01/09 Assessment and Treatment Plan - Residential Care Centers for Children and Youth (PDF)
DCF-F-2440 01/09 Assessment and Treatment Plan - Residential Care Centers for Children and Youth (Word)
DCF-P-PFS4067 11/08 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
DCF-P-PFS4089 09/09 DCF 54 - Child Placing Agencies - Annotated
DCF-P-PFS4097 08/09 Instructions for Ordering Forms - Child Placing Agency
PFS-4098 11/08 Instructions for Ordering Forms - Shelter Care & Group Foster Homes
DCF-P-PFS4099 07/09 Instructions for Obtaining Licensing Rule Books, Annotated Rule Books and Commentary Manuals
PFS-4100 02/06 Personnel Requirements - Group Foster Homes for Children

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Last Revised:  November 17, 2009