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DX' Z9d*>Ee=>D7 c|rCbYJ;KV"J^2ԤgwdH^Fnz9Df;0rʓ e?m~{xOU5 A۷il?GT&wtT=p'&!p glBI򾺵XB+9[z{j }lGn lg>R<re#  2tvw#UNK % 0: U"N ^ ' w3 47 K Z m\ Ns s 0cu 1u 72M 0w 0 0 0  0 0 0v 0De 1u 72$P 0Vttt B>fafafaf)a+f?aAfUUaWfkamfafafafafafafafa Bu11111111fNaPfdaffza|fafafaHP LaserJet 4100 Series PCL,,,,0(9 Z6Times New Roman RegularX($USUS.,(9 Z 6Times New Roman Regular7Z 4<7fs.drw3|xU(;3$2#  0  .3  0  3#37=CIQYag1.a.i.(1)(a)(i)1)a)i)(O;$0  2#  a  .3  0` (#(#(b$0  0` (#(#2#   .3  0 ` (#` (#(xir$0  0` (#(#0 ` (#` (#2#(  0  )3  0 (# (#($0  0` (#(#0 ` (#` (#0 (# (#2#(  a  )3  0h(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#2#(   )3  0h(#h(#($0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#2#  0  )3  0(#(#({$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#2#  a  )3  0p(#(#(F$0  0` (#(#0 ` (#` (#0 (# (#0h(#(#0h(#h(#0(#(#0p(#(#2#     )3  0p(#p(# x3MQUY]aeiBullets List  w h(.3$ !USUS.,   dTABLE GTABLE HTABLE QTABLE RTABLE ETABLE STABLE JTABLE TTABLE ATABLE PTABLE BTABLE UTABLE CTABLE VTABLE D dTABLE XTABLE LTABLE MTABLE NTABLE YTABLE O !USUS.,  _hh:wX|XXX<XX|*13Xddd Xdd Xdd X:a&:a&, dd ,dd , dd +  $hh $  $DD,#XX$StateofKansas d DepartmentofSocialand j RehabilitationServices  ChildrenandFamilyServices '>  '@@@\REPORT/REQUESTFORSERVICES d @\\+\ 'j '  CFS1001 d January2007 j Page1of2" 0 "R*45dXd dd  dd  dd  13:a&:a&,dd ,dd ,Xdd ,dd ,dd ,dd ,dd ,dd ,dd ,Fdd ,dd ,dd +  't  t  'ЀCaseName: ;*!p  ;  3)p  3Case# 7&!p  7 0&p  0Event# 7&!p 7 5+p 5ReportDate 7&!  7 0&  0Time: 7&!  7 -cccc  -X 7& cccc 7am 6cccc#!  6 7& cccc 7pm =3!  =  Countywhereincidentoccurred: :)$ 0 : X# 9/    9PersonReceivingReport: >-$< > 3)< 3Area 7&!< 7 0&< 0FACTS_Wkr_Ԁ# 7&!< 7(<   (*=67d ddd dd Xdd Xdd dd dd dd dd dd Fdd Fdd dd 45:a&:a&=,B 66 ,66 ,66 ,66 ,e66 ,66 ,66 ,66 , 66 +  $   $XffReportMedium:(Markone) 'ccccn  ' -#n!cccc -Fax[F], 'ccccn" ' -#n#cccc -Mail[M], 'ccccn$ ' -#n%cccc -Phone[P], 'ccccn& ' -#n'cccc -Walkin[W]"n( "*89d dB 66 B 66 66 66 e66 e66 66 66  66  67:a&:a&,'$dd +  $( $SectionI"Z ) "ff X *e:;dd'$dd '$89:a&:a&e,T$dd +  ) z) z <)@dINFORMATIONFROMTHEREPORTER ,"F * < ,Descriptionofcircumstancesorconditionsthatledthereportertomakeareport.Whytoday? '  + '  Ifthereporterallegesabuseorneglect,askthereportertoprovidedetailedinformationconcerning:  L , 1)Ageofchild(_ren_)?2)Descriptionofharm\injuries,howoccurred,whereandwhen,orhasthishappenedbefore?3)Whocausedharm\injury? R - 4)Doeshe\shehaveaccesstothechild?5)Otherindividualsoragencieshavinginformation?  .   " /   T0   1 M P2 M   3   74   i5   36   e7   8   19   c:   -;   _<   =  +!>  *e<>ddT$dd T$:;:a&:a&e, dd , dd +  $! >!  $SectionII  ']" ? 'SectionIII"]" @ "*x?@dddd dd <>:a&:a&x, dd ,Hdd +  $!#!@!#! $LocationofChild:Wherecanthechildbelocatednow? '#"A 'Prior_SRS_ԀInvolvement: #"B   $O#C   $O#D   %$E  %$F  *xABdd dd Hdd H?@:a&:a&x,$dd +  $&O%F&O% $|SectionIV"'%G "|*eCDdd'$dd $AB:a&:a&e,dd ,Sdd ,dd ,dd , dd ,dd ,Xdd ,edd ,dd ,dd +  ('_&G'_& (ReporterName: (+(&H ( 4*+(&I 4Address(street,apt.#) (])'J ( 5+])'K L5City *')L   *')M County *')N   *')O State *')P   *')Q ZIP *')R   *')S Phone# *')T *')U L  *EGd ddd Vdd Sdd dd  dd dd Xdd Xfdd edd dd CD:a&:a&,xdd ,dd ,dd ,dd ,dd ,dd ,}dd ,dd ,dd ,dd ,dd +  -#w+*Uw+* A -ReportSource(Relationship)checkonlyone: :0+s*V A   : 9ccc&!,P+W  9 0&,P+Xccc 0SocialService[_SSP_] 9ccc&!,P+Y 9 0&,P+Zccc 0Medical[MED] 9ccc&!,P+[ 9 0&,P+\ccc 0Legal[_LGL_] 6ccc#!,P+] 6 0&,P+^ccc 0Education[EDU] 6ccc#!,P+_ 6 0&,P+`ccc 0Anonymous[_ANO_] LB',P+a   L 9ccc&!V-+b 9 0&V-+cccc 0Victim[VIC] 9ccc&!V-+d 9 0&V-+eccc 0Parent[PAR] 6cccc#!V-+f 6 0&V-+gcccc 0Relative[REL] 6cccc#!V-+h 6 0&V-+icccc 0Neighbor[_NEI_] 6cccc#!V-+j  6 0&V-+kcccc 0Friend[_FRN_] I?,V-+l   I 'ccc.,m ' 0&.,nccc 0DayCareProvider[_DCF_] 6cc#!.,o 6 0&.,pcc 0SubstituteCare[SUB] ?cc,!.,q ? 9/!.,rcc 9Other[_OTP_]Specify: 4*!.,s 41'%.,t   1#<#<XX|#<<=#<<Ԁ 0&! B 8 0 7&}  9 7Date: -#!}  : -}  ; 0  *^_d didd idd dd dd &dd &dd dd  dd dd \]:a&:a&,$dd +  $W ;W  $pffSectionVIPreliminaryInquiryREQUIREDoncurrentopencasesandifanyfamilymemberorallegedperpetratorhaspriorCFSinvolvementandnofurtherCFS  D < actionneeded.#<< ?##X|X<>#X|XXX|<XX|"W = "p:A*e`add'$dd $^_:a&:a&e,edd ,dd ,dd , dd ,dd , dd +  0&# =#  0 6cccc#!> 6 4*?cccc 4ADDITIONALINFORMATIONNEEDEDTOCOMPLETETHEINITIALASSESSMENT: OE/@ d   O 9/!%A 9 9/!%B  9REQUESTED:Date/Timed -#!%C  - ! %D !dDATEDUE:d 7&!%E  7 =,%F  =d     "  N  z     *      "  N  z     *  V          2  ^          :  f       1'%ZJ   1*klddedd edd dd  dd dd  dd `a:a&:a&, dd ,dd ,,dd , dd ,,dd ,dd +  )7J7 )SectionVIIINITIALASSESSMENTDECISION#<,Y   Qd -#&Zccc -NOFURTHERCFSACTIONNEEDED#<<1J##X|Xnccc 4Reportfailstoprovidetheinformationnecessarytolocatechild[FPI] TccA/>o   T 4*epcc 4Reportisknowntobefictitiousand/ormalicious[FRP]CFSProgramAdministratorsapprovalrequired. Occ</eq   O 4*zrcc 4SRSdoesnothaveauthoritytoproceedand/orhasaconflictofinterest[NAP] Jcc7*zs  J 4*tcc 4IncidenthasbeenorisbeingassessedbySRSand/orlawenforcement[AAS] Lccc9*u  L 1'?vccc 1Reportindicatesfamilyhasorwilladdressconcernsontheirown[FAC]NONABUSE/NEGLECTONLY @c- ?w   @ 4*Z xc 4Reportindicatestheconcernhasbeenreferredtooristheresponsibilityofanotheragency[OAC]NONABUSE/NEGLECTONLYd:0.Z y  :d*qrd ddd dd 8"dd )"op:a&:a&,'$dd +  # y  #  BASISFORNOFURTHERCFSACTIONNEEDED#<