WPC  i+Nt3QM%-ıB8 edp#^w*+tjč]^jH!H*]gl-8#_D9r}_OC*I`F3:K|_DCg*`•\ m0~@|kc &@ha%E$!F3ҾUh")l1 l|k<(¡a`焗v}Z*,.%^*vtTnگTųZgsUNڢSY%0N{Rl }uC?jG;Pؒ4ʚؓ]`_sSV  Mb'zf(`T:j;TEIʃszg:u7HjmUj'0̱^Y/t%DW ա)͈{&8Lr%E: N<~}'ƝPu#Zdi>ͧέ# U'N % 0: f% 0V'^ }w4 mfffafafafffaf)f+f-a/aCfWaYamafafaafaaNfafaf-a/fCaEaY 1m 72 1& 72 1u 72T 0 c 1 72pfafafafaUfOaQaefya{fafafa B B B' B*................................................. BcXHP LaserJet 8100 Series PS0(hH  Z6Times New Roman RegularX($USUS.,(.3$ !USUS.,  ]y3 33(Backup3|xU᠛TABLE BTABLE CgTABLE Dp,P TABLE F8UVTABLE GTABLE EX.TABLE HTABLE LTABLE JX.TABLE IWTABLE KTABLE MTABLE NTABLE PTABLE OTABLE QxQTABLE R TABLE STABLE A(CEKQW]cioAutoList2A.A.A.A.A.A.A.A.5A.(CEKQW]cioAutoList1A.A.A.A.A.A.A.A.7A.3#37=CIQYag1.a.i.(1)(a)(i)1)a)9i)(;3$2#  0  .3  0  (CEKQW]cioAutoList3A.A.A.A.A.A.A.A.<A. TABLE UnTABLE WTABLE TjTABLE V K 'USUS.,  _XX^?\XX*QZRddd Xdd Xdd XX%X%, dd , dd , dd +  'HH '( \^?  StateofKansas d DepartmentofSocialandRehabilitationServices J ChildrenandFamilyServices#^?\ (# 9/!   9 9/!d  9  Form2030A d Rev.July20011'%60  1TABLE XTABLE YhTABLE ZTABLE AATABLE ABTABLE AC d  d d&0 d d_QuintupleE d d d d d !USUS.,  _HXXXFŘXX *BCddd Xdd Xdd XX%X%,(#dd +  $@@ $X'XŘ@"AGENCYRESPONSE#ŘXX'#&&%ŘԀ##D% #Ř%&&#^?\ŘPage1of2#Ř\^?Q#&&%Ř  d  @#Ř%&&#X'XŘ(FamilyBasedAssessmentonly)#ŘXX'# 'P '&&%Ř STATUS: #Ř%&&#     IdentifyingInformation:"   " *lZdd(#dd (#BCX%X%l,dd , dd ,dd ,dd ,Fdd ,dd +  '   'CaseName: 7Z&!>   7 0&> Z 0FACTSCase# 7Z&!>   7 0&> Z 0FACTSEvent#: 7Z&!>    7(>   Z (*Zdddd  dd dd dd Fdd Fdd ZX%X%,dd ,dd ,dd ,dd +  '2  2  'SocialWorker: 0&! V   0 0& V  0DateofAssignment: 0&! V   0( V  ( *>?dddd dd dd dd ZX%X%,(#dd +  +f J J + 1'%  f 1 *lDEdd(#dd (#>?X%X%l,(#dd +  $>> $&&%Ř@ SectionI:DeterminationofChildSafety#Ř%&& #  b @CompleteOnlyforChildAbuse/Neglect "z:  " *lZdd(#dd (#DEX%X%l,` dd ,Sdd ,dd , dd +  'n. n.  '',XX'!ŘA.0  NameofAllegedVictim: G=+B T T    G@11 VAttemptstolocate   B.Date/Time~~+C.Location <2$B   <D.Whoattempted/madecontact 5+!B  L 5 '   ' '   ' '   '-#!  L    -*Zdd` dd ` Sdd Sdd  dd ZX%X%,dd ,dd +  'n n  ' <(839! !";3"  ;32  E  .3  0    Results:;3>݌ :0+  :Ќ  0&  0 0&!V 0(V   (*Zdddd dd ZX%X%," dd , dd ,dd ,dd ,dd ,dd , dd +  .f66 .F.Dateandtimesafetywasdetermined: 7f&!Z f 7 7f&Z!f 7G.ChildSafe: 6llfl#!Z"f 6 7f&Z#llfl 7Yes 6llfl#!Z$f 6 7f&Z%llfl 7No1'%Z& f 1*Zdd" dd "  dd  dd dd dd dd dd ZX%X%, dd ,4dd ,4dd , dd +  'z:&z: 'A.0  NameofAllegedVictim: G=+N(     G@|| Attemptstolocate ) B.Date/Time.qC.Location <2$N*  <D.Whoattempted/madecontact 0&!N, 0 '-  ' '.  ' '/  '(0    (*Zdd dd  4dd 44dd 4 dd ZX%X%,dd ,dd +  'r0r 'E.0  Results: :0+1 : 0&2 0 0&!Z3 0(Z4   (*"Z#dddd dd ZX%X%, dd ,/ dd ,dd ,dd , dd ,dd ,dd +  .f:4: .F.0  Dateandtimesafetywasdetermined: Af0+^5  f A 7f&^6f 7G.ChildSafe: 6llfl#!^7f 6 7f&^8llfl 7ЀYes 6llfl#!^9f 6 7f&^:llfl 7No1'%^; f 1*Z!dd dd / dd / dd dd dd dd dd "Z#X%X%, dd ,dd ,dd , dd +  '~>;~> 'A.0  NameofAllegedVictim: G=+R=     G@  0Attemptstolocate > B.Date/Time,C.Location <2$R?  <D.Whoattempted/madecontact 0&!RA 0 ' B  ' ' C  ' ' D  '( E    (*$Z%dd dd  dd dd  dd Z!X%X%,dd ,dd +  ,"!vE!v S, 7(88<! !";3"  ;3x#2  E  .3  0    Results:;3x##݌ :0+"F :Ќ  5+"G S  5 0&!m#-H 0(m#-I   (*Z dddd dd $Z%X%X%, dd , dd ,dd ,dd ,Xdd ,dd ,dd +  .fM$ IM$  .";3"  ;3e&2  F  .3  0    Dateandtimesafetywasdetermined:;3e&&݌  Af0+$qJ  f A 7f&$qKf 7G.ChildSafe: 6llfl#!$qLf 6 7f&$qMllfl 7Yes 6llfl#!$qNf 6 7f&$qOllfl 7No1'%$qP f 1  +$X _ *HIdd dd dd dd dd Xdd Xdd dd Z X%X%,(#dd +  $@@ $X'X!@"AGENCYRESPONSE#!XX'"*#Ԁ^?\! ##D%Page2of2#!\^?*#&&%!  d  @#!%&&*#X'X!(FamilyBasedAssessmentonly)#!XX'Z+#  P  &&%!STATUS: |< #!%&&+# IdentifyingInformation:"T  " *l'Z(dd(#dd (#HIX%X%l,dd , dd ,dd ,dd ,Fdd ,dd +  '4 4  'CaseName: 7Z&! X  7 0& XZ 0FACTSCase# 7Z&! X  7 0& XZ 0FACTSEvent#: 7Z&! X   7( X  Z (*,Z-dddd  dd dd dd Fdd Fdd 'Z(X%X%,dd ,dd ,dd ,dd +  'x 8 x 8 'SocialWorker: 0&!    0 0&   0DateofAssignment: 0&!    0(   (*@Adddd dd dd dd ,Z-X%X%,(#dd +  +f | | +H 6,! f 6H:2 &&%!@ SectionII:PersonsInvolvedinInvestigation #!%&&2#Ԉ   &&%!@   Checkallthatapply#!%&&73#Ԉ"  "*l Z4dd(#dd (#@AX%X%l,,dd , dd ,,dd , dd ,+dd , dd +  $lll   $ 0&@ lll 0SRSSocialWorker 6lll#!@  6 0&@ lll 0LawEnforcement 6llll#!@   6 0&@ llll 0MultidisciplinaryTeam 6lll#!@  6 0&D lll 0CourtServiceOfficer 6lll#!D  6 0&D lll 0Others(Specifybyagency) 6llll#!D   6 0&D llll 0SRSSpecialInvestigator1'%D    1*&dd,dd , dd ,dd , dd +dd + dd Z4X%X%,(#dd +  +fd$ d$  +H1'%  f 1H8&&%! *lJdd(#dd (#&X%X%l,(#dd +  $@ @  $@__SectionIII:Contacted/Interviewed d  @    Checkallthatapply #!%&&N9#  |<  Ř!Ifanypersonlistedwasnotcontactedand/orinterviewed,documentwhy.(Indicatedateofthecontact/interview,howinterview T! wasconducted(facetoface,phone,observed,etc.)Andwheretheresultsofthecontact/interviewcanbelocated).#!Ř:#&&%!"" "#!%&&#<#*lZ*dd(#dd (#JX%X%l, dd ,Fdd ,m dd , dd ,dd +  ," "  I, ALLEGEDVICTIM(S) 9/!p0# 9Name(Last,First) 9/!p0$" 9 9/!p0% 9Date: 9/!p0& 9 >4&p0' I  >Howinterviewwasconducted: 4*!y(   4 7-y)   7 <2$y*  <Whereresultscanbelocated: 4*!+   4 7-,   74*(-    4*KLdd dd Fdd Fm dd m dd dd Z*X%X%,(#dd +  $- $<"A. "<A*l.Z/dd(#dd (#KLX%X%l, dd ,Fdd ,l dd , dd ,dd +  'm.m ' CAREGIVER(S) 9/!/ 9Name(Last,First) 9/!0 9 9/!1 9Date: 9/!2 9 9/!3 9Howinterviewwasconducted: 4*!U4   4 7-U5   7 <2$U6  <Whereresultscanbelocated: 4*!Y7   4 7-Y8   74*(Y9    4*MNdd dd Fdd Fl dd l dd dd .Z/X%X%,(#dd +  $y99y9 $I": "IF*l0Z1dd(#dd (#MNX%X%l, dd ,Fdd ,l dd ,dd ,dd +  'V :V  ' ALLEGEDPERPETRATOR(S) 9/! z; 9Name(Last,First) 9/! z< 9 9/! z= 9Date: 9/! z> 9 9/! z? 9Howinterviewwasconducted: 4*!!@   4 7-!A   7 <2$!B  <Whereresultscanbelocated: 4*!B#C   4 7-B#D   74*(B#E    4*OPdd dd Fdd Fl dd l dd dd 0Z1X%X%,(#dd +  $"$E"$ $<"$FF "<K*l2Z3dd(#dd (#OPX%X%l, dd ,Fdd ,l dd , dd ,dd +  '$F$ ' OTHERPERSONSIDENTIFIEDBY V%G SOCIALWORKERASRELEVANT 9/!&H 9Name(Last,First) 9/!V%I 9 9/!V%J 9Date: 9/!V%K 9 9/!V%L 9Howinterviewwasconducted: 4*!J' !M   4 7-J' !N   7 <2$J' !O  <Whereresultscanbelocated: 4*!(N"P   4 .$(N"Q   .+!(N"R    +