WPC Pm}fT .:K- Q?9O >)ȈtKC1*D2^x۞)Tިg";Ԕ5WQlXk&:7[^nLO )?54.#9xR1exQ3pl[L;sL\hZ l\-lcBS^zH^j$LKKt|W;KFJjW`*t6 wb*2! .}Fk6=m/m+LQϪ֞XLPuH L_x3~;Ҥr %qWQl%u]S۸etЙI koh(;@I~ (%F{ iewbttg+9+bͮIق] +rTr} @s;>4/P97G-h=SwE'~DZXwfkOpӞvs>g,V-+<|{j#U+N % 0( w 4 ) 8 v@  f f a a f f a a 1 72ff 1u CFf`fbad^ xaf B$ 72 0caN D3b m C ilaQaeeeefya{{N C B B* B*SAVIN 2055DP PCL 60(@ Z 6Times New Roman RegularX($_,3|xCFS1004, Determination of child safety attachment  %9 ' DON0DON .   HTABLE BTABLE A\TABLE CTABLE D(CEKQW]cioAutoList1A.A.A.A.A.A.A.A.A.3#37=CIQYag1.a.i.(1)(a)(i)1)a)dTABLE K7, TABLE L di)(;3$2#  0  .3  0  TABLE H 'dxdUd$  bTRX3' LetterO'3 Letter Landscape3' Letter'3 Letter LandscapeTTABLE ETABLE GTABLE N d  d&0 d d d !  _hTRO'3 Letter LandscapeX3' Letter'3Letter Landscape3'LetterT(a** ' d dd Xdd Xdd X11, dd ,pdd ,0 dd +  )hh )%  &%%XX,A,%&%ԀStateofKansas d KansasDepartmentofSocialandRehabilitationServices < ЀChildrenandFamilyServices#&%%,,A# 'D '@@@0 AGENCYRESPONSE  d @&(FacilityandThirdPartyReports) '0 '   b%&%CFS1004 d July,1999 b Page1of2#&%% b#'0  '* 'd  d dd  pdd p0 dd 0 11,dd ,dd ,dd , dd ,dd ,dd +  0&VV 0 F<)"     F%&%CaseName: @ /!   @ 9/!   9Case#: @ /!   @ 9/!   9Event#: @ /!  @ G=&    GX39/-f    93 X  * 'dddd dd dd  dd dd dd  11,dd ,dd ,dd ,Sdd , dd ,Fdd ,dd ,#dd +  0&VV 0 SectionI G=)R   G@( DETERMINATIONOFCHILDSAFETY 8.    8H A. R  @NameofAllegedVictim <2#  <@ Attemptstolocate .$R  .D. R  @hh.Whoattempted/made   @3contact: <2# 6 CC <E. R  @!!F"Results <2#  <! ! (83F.Dateandtime R  Safetywas   Determined <2# 6 CC <G.ChildSafe * R    * ! 1  !B.@ ? Date/Time ' -  'C.@ii#uLocation " -  "  1    1   % 1  %YESs0s0gK1NO ! - ! !# H0 #   p "    p #    p $    p %    p &    p '    p (    p )   $ *   $ +   $ ,   $ -   $ .   $ /   $ 0   $ 1   p2   p3   p4   p5   p6   p7   p8   p9   T:   T;   T<   T=   T>   T?   T@   TA   B   C   D   E   F   G   H   I   TJ   TK   TL   TM   TN   TO   TP   TQ   8R   8S   8T   8U   8V   8W   8X   8Y   Z   [   \   ]   ^   _   `   a   8b   8c   8d   8e   8f   8g   8h   8i   j   k   l   m   n   o   p  q   lq (a* (TRX3' LetterO'3 Letter Landscape3'Letter'3Letter LandscapeT (  hwd  ^;\*#'dddd dd dd Sdd S dd Fdd Fdd #dd # w%w%,$dd +  ) )g  CFS1004#\^;s#,A, &d July1999#,,A#H   # Hw#,A,Page2of2#,,A#^;\',0  '#\^;#*k ' dd$dd $#w%w%k,#dd +  dWd  ,A, ," .,Jd: #,,AV#f`+SectionII ,A,6,*$ .  6#,,A$#f+ X X *e * d d#dd # w%w%e,,dd ,rdd ,dd , dd ,dd ,dd ,dd ,wdd , dd +  +! +#XX # Personsresponding:  R (Checkallthatapply) Miii:50  Mz || 4*Riii 4ЀSRSSocialWorker Miii:5R M 4*R iii 4LawEnforcement Jiii72R  J 4*R iii 4_Multidisciplinary_ԀTeam B82R  B||T! $   $J#| 1'!$b  1 $   $ 1'!$b 1 $  $ 1'!$b 1 $i i  $ 4*4ri i  4Others(Specifybyagency) |# 7-$4r   7+!4r    +* +d  d,dd ,rdd rdd  dd dd dd dd wdd w dd   *w%w%,5dd ,dd ,dd , dd +  1 ZZ 1 SectionIII =3$  =' PersonsContacted/Interviewed(Checkallthatapply)Ifanypersonlistedwasnotcontactedand\orintervieweddocument   why. (Indicatedateofthecontact\interview,howinterviewwasconducted(facetoface,_phone,observed,etc_.)andwheretheresults L  ofthecontact\interviewcanbelocated). *i ii >  *'1$ 4*H i ii  4 ALLEGEDVICTIM(S): 3)$H   3 (H  ( % `  % *i iix  *Ѐ 0& i ii 0 _CAREGIVER_(S): ; *!   ; +!   +1$Y) (  ( 9i ii&$  9 4*!i ii  4 ALLEGEDPERPETRATOR(S): : )$"  :X X (#  (E+A,.$  ,*  d d5dd 5dd dd  dd  +w%w%,,dd ,dd ,dd ,-dd +  ($ ( #XX S,#OtherPersonsIdentifiedbySocialWorkerasRelevant. *i iiF% *D.|+ 0&T&i ii 0Sibling(s): ; *!T'  ; +!T(  + % d) % *i iit* *Ѐ 4*+i ii  4OtherHouseholdMember(s) 3)$,  3 / - / < -.   < 9i ii&$/  9Ѐ 0&0i ii 0Other_Caregiver_(s): 4*!1  4 2 !2 2 7-3   7 9iii&$4  9 0&"5iii 0ЀWitness(es): 4*!"6  4 +!"7 + (  28 ( 9iii&$"B 9 9Ѐ 0&#R!:iii 0Other(s): 1'!#R!;  1  #R!< |+.f$$b"=   f43 H *  d d,dd ,dd dd -dd - w%w%,dd ,ydd ,dd ,Pdd ,Ndd +  +!%>#=%># +|SectionIV# H^4#H  @6$d%#> @# H6#H   MEDICALSCREEN 9/$t&$?  96Wasamedicalexaminationortreatmentrelatedtoabuseorneglectneeded?0  1 iii'%@ 1Ѐ# H6#H  -#'%A iii -# H7#H NO# H@8# ' iii'%B ' -#'%C iii -H YES# H8#H  5 $'%D 5RRb%# H9#Ԁ(Ifno,explain.IfYes,describereasonableactionstakentoprovidemedicalcare.)H Ԉ 4*$(&E  4# H9#  )'F |5|*(G   |:*/ 0 d ddd ydd ydd Pdd PNdd N w%w%,dd ,dd ,Ndd +  + `+)G`+) +SectionV 9/$+*H  9WorkerSignature:0q * -N+I *Date: 0&!-N+J 0 -#-N+K -Supervisor\DesigneeSignature: * \.,L *Date: 0&!\.,M 0(\.,N   (