WPCL (Y\`ΆR; P]Wwt%t<"2 跔Q WlIc]HwwÅ͉4fy* v$:,ƻʟVyU? ]d;q?Հ@kPY %z= ~K|_Z|̐ȓPk!PDE" I8#4PR Pac`RTNV<5=kyaa;eql{U)FR)#>UN %U 0([wU>4 0P 0D NM U7HO ^ UPH U H 3 m5 L  U,% % 6Q Q Q Q Q Q Q Q Q 0D AHP LaserJet 8150 Series PCL,,,,0(9 Z 6Times New Roman RegularX($(\  p`&Times New RomanS53|x   '  _  @II7 $0XXCFS1000Instructions   @  @`  @  @  @h  @  @  @p  @  @   @x  @ January,2006 ^  @  @`  @  @  @h  @  @  @p  @  @  Page3of3((3/Q$ !   d (3$ !  .\' AZ0Univers (W1) RegularB~T5 .&b AZ0Univers (W1) Regular.\' AZ0Univers (W1) RegularU   '  _0XX  @hh6(#CFS1000Instructions   @  @`  @  @  @h  @  @  @p  @  @   @x January,2006 ^  @  @`  @  @  @h  @  @  @p  @  @   @x Page1of3-kAZArial  ,  '  _   @  @`  @  @  @h  @  @  @p  @  @  0XXCFS1000Instructions   @  @`  @  @  @h  @  @  @p  @  @  January,1998 ^  @  @`  @  @  @h  @  @  @p  @  @  Pg.2of3 @x  @ (3$ !   {  <<= 8C !  _\њR    XFXXX ŶX XF*X, XX*8  dd8COMPLETINGTHEFACESHEET,FORMCFS1000  Ŷ& %  n   # &{w % %& E## Ŷ % &{wd#Ŷ ŶŶŶItisthepolicyofthedepartmentthattheCFS1000,"FACESHEET"shallbecompletedonALLreports  andallegationsreceivedbythedepartment.  Xl  Informationisrecordedonreceiptofareportorallegationandadditionalinformationisaddedasit   becomesavailable.Whennewinformationisaddedtotheform,initialanddatethenewentry.     X X   SectionI  J ^ Listallchildreninthehouseholdorifachildfacility,listinvolvedchildren.    .0  CHILDNAME:  Enterthenamesofallchildreninfamilyorthenameofthechildifalleged r  perpetrator.#ŶŶ #Listinorder:lastname,firstname,middleinitial.Ifalicensedfacilityeachinvolved <P  childorinvolvedsiblinggroup.ŶŶ (#(# .0  DOB/EST: ` Enterthedateofbirthforeachperson#ŶŶ# ŶŶ(MM\DD\YYYY).#Ŷ Ŷ#ŶŶԀIfthedateofbirthisnot   available,estimatethedateofbirthfromtheageoftheperson.Ifdateofbirthisanestimate, dx  indicatewithacheckmark..B(#(# 0   (#(# .0  SSN:  4 Enterthesocialsecuritynumberforeachperson.(IfSSNisnotavailabledonotentera  manufacturednumber).(#(# .0  SEX:  4 Enterthesexoftheperson:0(#(#Female[F];Male[M] 4(#(# .0  RACE:  4 Entertheraceofeachperson:0(#(#(#(# 0  0(#(#04(#(##ŶŶ# ŶŶAmericanIndian[AI]0<4(#4(#0h<(#<(##Ŷ ŶK # ŶŶWhite#Ŷ Ŷ # ŶŶԀ[WH]~h(#h(# 0  0(#(#04(#(#Asian[SA]0 4(#4(#0 (# (#0 (# (#0<(#(#0h<(#<(#Unabletodetermine[UK]H\h(#h(# 0  0(#(#04(#(#Black[BL]0 4(#4(#0 (# (#0 (# (#0<(#(#0h<(#<(#NativeHawaiian/PacificIslander[HP]0 h(#h(#& (# (# 0  0(#(#04(#(#0` 4(#4(#0 ` (#` (##Ŷ Ŷ #ŶŶ  (# (# .0  ETHNICITY: EntertheHispanicethnicityofeachpersonifapplicable:0 (#(# (# (#      4  `  #ŶŶ # ŶŶSEEFACTSUSERMANUALFORCODES#Ŷ Ŷ#ŶŶ p 0  0(#(#04(#(#0` 4(#4(#0 ` (#` (#0 (# (#0 (# (#  (# (# 0  0(#(#04(#(##ŶŶ5# ŶŶMexican[ME]0 4(#4(#0 (# (#CentralorSouthAmerican[CS]#Ŷ Ŷ[#ŶŶ !(#(# 0  0(#(#04(#(##ŶŶ# ŶŶPuertoRican[PR]04(#4(#OtherSpanishCulturalOrigin[OS]#Ŷ Ŷ#ŶŶ "(#(# 0  0(#(#04(#(##ŶŶ # ŶŶCuban[CU]0 4(#4(#0 (# (##Ŷ Ŷ# ŶŶUnabletodetermine[UK]#Ŷ Ŷ# ŶŶ!#(#(# #Ŷ Ŷp#ŶŶ.0  TRIBE:  4 Enterthetribeofeachpersonifapplicable:0D(#(#,#@%D(#D(#   #ŶŶ#ŶŶ0  04(#(##ŶŶ# ŶŶSac&Fox[SF]04(#4(#0<(#(#0h<(#<(#0h(#h(#0(#(#Iowa[IA]#Ŷ Ŷ #ŶŶ$'(#(# 0  0(#(#04(#(##ŶŶ# ŶŶPotawatomi[PT]04(#4(#0<(#(#0h<(#<(#0h(#h(#0(#(#Other[OT]#Ŷ Ŷ]#ŶŶ%((#(# 0  0(#(#04(#(##ŶŶ# ŶŶKickapoo[KI]#Ŷ Ŷ#ŶŶ0 4(#4(#0 (# (#0<(#(#T&h )<(#<(# .0  LIVESWITH:  Identifytheadult(s)withwhomthechildlivesbyenteringthenumber(s)bythe '!+ namefromthe ADULTINFORMATIONsection.(",(#(# .0  SCHOOLATTENDS:  Ifchildattendsschoolorchildcare,enternameofschool/center/home F*Z$. wherechildattends.+$%/(#(# .0  SCHOOLDISTRICT: 󀀀#ŶŶ# ŶŶIfthechildisinschool,#Ŷ Ŷk#ŶŶenterthethreedigitnumberoftheschooldistrict ,&1 wherethechildattends#ŶŶ# ŶŶ[seeFACTScodelisting]#Ŷ Ŷj#ŶŶ.Ifthechilddoesnotattendschoolleaveblank. n-'2 Ifchildisattendingaprivateschoolorisbeinghomeschooled,entertheschooldistrictwherethe 8.L(3 school/homeislocated./)4(#(#  `1t+7 Ї .0  DISABILITYTYPE: 󀀀Enterthedisabilitytype(s)ofeachpersonifapplicable:0L(#(##ŶŶ#ŶŶL(#L(# #ŶŶ# ŶŶ0  Ifpersonlistedisknowntohaveadiagnoseddisabilityentertype.(Donotguessorassume)#Ŷ Ŷ#(#(# 0  0(#(#04(#(#0` 4(#4(#0 ` (#` (#0 (# (#0 (# (#0 (# (#0<(#(# <(#<(# 0  EmotionallyDisturbed[ED]0<(#(#NotDetermined[ND]0D<(#<(#0pD(#D(#0p(#p(#PhysicalDisability[PD] ((#(# 0  HearingImpaired[HI]0 (#(#0 (# (#0<(#(#SightImpaired[SI]0<(#<(#0D(#(# p   LearningDisability[LD]0 D(#D(#  (# (# 0  Speech[SP]0 (#(#0 (# (#0 (# (#0 (# (#0<(#(#OtherDisability[OD]0D<(#<(#0pD(#D(#0p(#p(#MentalRetardation[MR] (#(#   None[NO]0 ` 0 ` (#` (#0 (# (#0 (# (#0 (# (#0<(#(#r <(#<(# ŶŶ    #ŶŶ ##ŶŶ.0  ROLE:  4 Entertheroleofeachpersoninthefamilyrelatedtothisevent:  (#(#      4 #ŶŶf##ŶŶ0    #ŶŶU$# ŶŶAllegedPerpetrator[ALP]0<(#(#0h<(#<(#AllegedVictim[ALV]0ph(#h(#0p(#p(#NotInvolved[NIV]#Ŷ Ŷ$#ŶŶdx (#(#     #ŶŶ%# ŶŶCollateralWitness[CLW]0 < 0h<(#<(#FamilyMember#Ŷ Ŷ%# ŶŶԀ#Ŷ Ŷ&# ŶŶ[FAM]#Ŷ Ŷ&# ŶŶԀ#Ŷ Ŷ '#ŶŶ.B h(#h(# 0  AchildallegedtobeaCINC\NANorJOiscodedFamilyMember (#(#  X   SectionII  Vj  Enterthenamesofadultsinthefamilyandthenameoftheallegedperpetratorifdifferent.  Thecasenameislistedasadult#1orchildifPRT. ~ .0  MARITALSTATUS: 󀀀Enterthemaritalstatusofeachadult:&(#(#      4  `   #ŶŶM'#ŶŶ   0  0(#(##ŶŶ)# ŶŶCommonlaw[CL] 0(#(#0<(#(#Divorced[DV]0<(#<(#0(#(#0D(#(#LegallySeparated[LS]#Ŷ ŶS*#ŶŶpD(#D(# 0  0(#(##ŶŶ7+# ŶŶMarried[MA]0 (#(#0 (# (#0 (# (#0<(#(#Widowed[WI]0<(#<(#0(#(#0D(#(#Separated[SE]#Ŷ Ŷ+#ŶŶ:ND(#D(# 0  0(#(#Single[SI](#(# .0  RELATIONSHIPOFADULTTOCHILD: Enterthechildsletterandtherelationshipcodeforthis  adult:bv(#(#      4  `       <  h   #ŶŶ,#ŶŶ0  0(#(#   0(#(#0(#(##ŶŶ.# ŶŶFather[FA] 0 (#(#0 (# (#0<(#(#AdoptiveSibling[AS]0D<(#<(#0pD(#D(#0p(#p(#0(#(#Uncle[UN]#Ŷ Ŷ./# ŶŶ0L(#(#0xL(#L(#0 x(#x(#0@ x(#x(#0@ x(#x(#0@ x(#x(# " (# (# 0  #Ŷ Ŷ20# ŶŶ  Mother#Ŷ Ŷ1# ŶŶԀ[MO]  #Ŷ Ŷk1# ŶŶ0(#(#0<(#(#Sibling[SI]#Ŷ Ŷ1# ŶŶ0<(#<(#0(#(#0(#(##Ŷ Ŷ@2# ŶŶ0D(#(#0pD(#D(#0p(#p(#0(#(#Nephew\Niece#Ŷ Ŷ2# ŶŶ[NN] #Ŷ Ŷ]3# ŶŶ0@ p(#p(#0@ x(#x(#!#(#(#     Step#Ŷ Ŷ3# ŶŶParent#Ŷ ŶU4#Ԁ[St] ŶŶ0 0 (# (#0<(#(#StepSibling#Ŷ Ŷ4# ŶŶ[SS]  #Ŷ Ŷ%5# ŶŶ D 0p<(#<(#0p(#p(#0(#(#PaternalGrandparent#Ŷ Ŷw5# ŶŶԀ[GP]0@!(#(#  Ŷ0@!x(#x(## Ŷ M6#T"h$(#(# 0  0(#(#AdoptiveParent[AM]0(#(#0<(#(##Ŷ Ŷ6# ŶŶAunt[AU]0<(#<(##Ŷ ŶA7# ŶŶ0(#(#0(#(#0D(#(#0pD(#D(#0p(#p(#0(#(#MaternalGrandparent#Ŷ Ŷ7# ŶŶԀ[GM]0@"(#(##2%(#(# Ѐ#Ŷ Ŷn8#ŶŶ    FosterParent[FP]   #ŶŶ8# ŶŶ  Ŷ0 < NotRelated# Ŷ ӓ9#Ԁ[NR]#Ŷ Ŷt9#ŶŶ  #ŶŶ:# ŶŶԀ0D<(#<(#0pD(#D(#0p(#p(#0(#(#Cousin[CO]#Ŷ Ŷb:#ŶŶ#&(#(#     #ŶŶ;# ŶŶFriend[FR]#Ŷ Ŷy;#ŶŶ0 0 (# (#0 (# (#0 (# (#0<(#(#HalfSibling[HS]0<(#<(#0D(#(#0pD(#D(#0p(#p(#0(#(#UnrelatedLiveIn_[UL] $'(#(#  X   SectionIII   .0  ADULT#orCHILDLETTER: Enterthenumberoftheadult(s)fromSectionII.Ifchildisnot  residingwithanyadultsinSectionII,entertheChildsLetter.J^(#(# .0  ADDRESS: 󀀀Enterthestreet,POBox,ApartmentNumber,City,State[seeFACTScodelisting],   ZipCode,County[seeFACTScodelisting],Typeofresidence[seebelow]anddaytimephone   numberforeachadult#orchildletternotlivingwithanadultinSectionII.r (#(# 0  TYPE: 04(#(##ŶŶ;#ŶŶ ` BusinessLocation[B]0h4(#4(#MailingAddress[M]0ph(#h(#0p(#p(#0(#(##ŶŶ?# ŶŶResidenceLocation[R]  (#(# #Ŷ Ŷ@# ŶŶ.#Ŷ ŶA#ŶŶ0  RISKSTOSOCIALWORKER: Specifyanyriskstothesocialworkergoingtothelocationofthe   familyorchildidentifiedbythereporterdx (#(# .0  #ŶŶbA# ŶLANGUAGESPOKENANDWRITTEN:#ŶB#ŶԀ Indicatetheprimarywrittenorspokenlanguageoftheallthe   familymembers. (#(#  &CF%0  #%&CFC#OTHERMEDIAUSED&CF%:#&{w %%&CFB#&{w % %&{wԀ#Ŷ %&{wC# Indicateifamemberofthefamilycommunicateswiththeassistanceof   othermedia.^r (#(#  X   SectionIV   ThissectionMUSTbecompletedforChildrenin_SRS_ԀCustody.Itcouldbeusefulinformationonany  casesituation.Informationmayberecordedherewhenachildisnotincustody. Pd #ŶŶ/D# ŶŶ.#Ŷ Ŷ[F#0  Providethenames,addressesandtelephonenumbersforparents,grandparents,andotherpersons  withwhomthechildhascloseemotionalties.Donotrepeatinformationthatisprovidedonpage(#(# ",US ,  (:!&),     4  `       <  h          D  p          L  x