WPCB; ^{PYtNV2sAH,8x.@767cYNp$ǕBaT}uMdAN&\Utڮ*j*8n-(ځ|JVBBI8vt0O4xM;y cyWASM/#cI"5\H_N(Bs=M \kX zߓiȥf󋾱42&i ;/j GWpq/~lhyc'V\) F,KG/bv4G@G|uK#0YіQ͓ҠM̢9ڇ}Ss`MV&jyuVmjM(0r%DH)lMC7p*}_,oyFiiΓN5PB:łŎ%j-f\|SX2+<]?9jȞ~wU >x 08 0K 0^ 0q 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0! 0" 0# 0$ 0% 0& 0`' 0>' 0$() 0*F+ 0-. 0/ 0b0 0(31 D+[1 AQ111111111f1a1 B 11 D/ 2f92a;2"O2"q2"22"2"2"2 1U3 7 p3"|3"3"33 03#4U :q7 %7M7(7N7^ 7w7478 m88 1u8 728888UD@888888888888888888888888899U>:U@;\  `&Times New Roman'   0SRS .   2[+[ 0_level1   , 8.p x(08"823  ..   8.p x(08"8  2[+[ 0_level2   X 8.p x(08"823  ..   8.p x(08"8  2[+[ 0_level3    8.Dp x(08"823  ..   8.p x(08"8  2[+[ 0_level4    8.pp x(08"823  ..   8.p x(08"8  2[+[ 0_level5    8. p x(08"823  ..   8.p x(08"8  2[+[ 0_level6    8. p x(08"823  ..   8.p x(08"8  2[+[ 0_level7   4 8. p x(08"823  ..   8.p x(08"8  2[+[ 0_level8   ` 8. p x(08"823  ..   8.p x(08"8  2[+[ 0_level9    8.Lp x(08"823  ..   8.p x(08"8  2[[ 0_levsl1   , 8.p x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl2   X 8.p x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl3    8.Dp x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl4    8.pp x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl5    8. p x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl6    8. p x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl7   4 8. p x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl8   ` 8. p x(08"823  Ԁ   8.p x(08"8  2[[ 0_levsl9    8.Lp x(08"823  Ԁ   8.p x(08"8  2[[ 0_levnl1   , 8.p x(08"823     8.p x(08"8  2[[ 0_levnl2   X 8.p x(08"823     8.p x(08"8  2[[ 0_levnl3    8.Dp x(08"823     8.p x(08"8  2[[ 0_levnl4    8.pp x(08"823     8.p x(08"8  2[[ 0_levnl5    8. p x(08"823     8.p x(08"8  2[[ 0_levnl6    8. p x(08"823     8.p x(08"8  2[[ 0_levnl7   4 8. p x(08"823     8.p x(08"8  2[[ 0_levnl8   ` 8. p x(08"823     8.p x(08"8  2[[ 0_levnl9    8.Lp x(08"823     8.p x(08"8  h:Default ParaDefault Paragraph FontXXX`:Footnote RefFootnote Reference($  0  @PP 0Level 1Level 1  X 8.p x(08"8  8.p x(08"8    #'..      JXXXJXX[XXJX  _    B.p x(08"XBXX[CFS1001Instructions  January2007 y     X[X(2$ H !..      JXXXJXXXXJX   < %)..      JXXXJXX[XXJX  __+sWGCz hX p @X@EX X x _ $$  $$  $$$$ _ (#(#$$_(2$ H !..      JXXXJXXXXJX  ݃ Level 1 Level 2 Level 3 Level 4 Level 5(2$ H !..      JXXXJXXXXJX  (2$ H !..      JXXXJXXXXJX  ($'dxd&'()*C<< cTable_A d6)1dxdTable_B            h               H   (359=AEIMQ1________B_            H   #|x( $..      JXXXJXXXXJXHP LaserJet 8000 Series PCL,,,,0,cAZ"Arial RegularJX,7 56:i+00U3#37=CIQYag1.a.i.(1)(a)(i)1)a)Ui)(mK Z(Times New Roman   '"..      JXXXJXuX[XXJX  _  uXuX[vu_P a g e _  1  _ o f _  4    #uv#\  `&Times New Roman(O Z(Times New Roman H !..      JXXXJXX[XXJX  __       "_$_  B.p x(08"XB ZX[XXX[ZXZX[COMPLETINGTHEREPORT/REQUESTFORSERVICES/INITIALASSESSMENT,FORMCFS1001       ItisthepolicyofthedepartmentthatinformationfromthereporterandInitialAssessmentdecisionshallberecordedon \d formCFS1001. #  Inmostinstancesthereporterwillnothaveallinformationthatisneeded.Inthissituation,itwillbenecessaryfortheintake  workertopromptthereporterforadditionalinformationortogatherthenecessaryinformationfromothersourcesif X ` available.     ,__ _  CASENAME: EnterthecasenameaslistedonPage1,SectionIoftheCFS1000.Thisnameshouldappearonall    formswhichaskforthe casename. T \    ,  ,__ _  CASENUMBER: 󀀀ThisnumberisassignedafterentryintoFACTS.EnterthenumberafterFACTSassignment.     ,  ,__ _  EVENTNUMBER: 󀀀ThisnumberisassignedafterentryintoFACTS.EnterthenumberafterFACTSassignment. PX    ,  ,__ _Ԁ  REPORTDATE: 󀀀Enterthedatethereportwasreceived:MM/DD/_YYYY_.     ,  ,__ _  REPORTTIME: 󀀀Enterthetimethereportwasreceived:00:00ampm. LT   ,  ,__ _  COUNTYWHEREINCIDENTOCCURRED: 򀀀 Entercountywheretheincidentoccurred [seeFACTSlisting].If  incidentoccurredoutofstate,enterstatecode.     ,  ,__ _  PERSONRECEIVINGREPORT: 󀀀Enterthename,areaandworkerFACTSnumberofthepersonaccepting  informationfromthereporter.    ,  ,__ _Z&e %Z  Z %Z&e REPORTMEDIUM: 󀀀Circlethemethodbywhichthereportisreceived: DL   ,  <$ hXX$Fax[F]0 Mail[M] h   Phone[P]    WalkIn[W]bj $ $   < SectionI    ,__ _   INFORMATIONFROMTHEREPORTER:WHYDIDTHEREPORTERCALLTODAY? ^f!  , ,DESCRIBECONCERNS:  %"  , ,Frominformationavailablefromthereporterorothersources,provideadetaileddescriptionofthereportwhichshould $ include: Zb%  ,  X  Adescriptionofcircumstancesorconditionsthatledthereportertobelievethereisafamilycrisisorachildisin  ' needofcare. !(   XӀ  X  Whatmotivatedthereportertocontacttheagencytoday? #* *45ddd Xdd Xdd X$$,!rr+  :6666'#+# :  Xd #,     dZ~ Z0 ` _ Practice_ԀNote:8$@ -`#`# 0 ` Ifthereportallegesachildhasbeenabused,neglected,orsexuallyabusedthereportershouldbequestionedabout:$ .`#`#  %!/   g  Ageofchild\children %!0   Adescriptionofanyinjuriesincludingtheloc_ation_Ԁandseverityofinjuries,howtheinjurieswereinflicted(i.e.openhand, &"1 closedfist,orwithaweapon). O'W#2   Theidentityoftheallegedperpetrator(s) '$3   Whetherandwhentheallegedperpetratorhasaccesstothechild ($4   g ,Askwhythereporterbelievestheallegedabuse/neglectorothersituationisoccurring.Forexample:didabuseoccurbyexcessive )%6 "discipline"orwasittheresultofadeliberatedesiretoharmthechild?Isallegedneglectofachildduetoproblemsthe U*]&7 caretaker(s)havesuchaslimitedintellectualfunctioning,chronicmentalillness,drug/alcoholdependenceorotherfactors?When, + '8 whereandhowoftendoestheallegedabuse/neglectoccur?Itisveryimportantthattime,place,frequency,and_chronicity_Ԁof +'9 abuse/neglectbeaddressed. Y,a(:  , 0 ,Askwhatotherindividualsoragenciesmighthaveinformationregardingtheallegedabuse/neglectorothercircumstancesandhow -)< tocontactthem.Z Z~<20].e*=  6666 < 0 ,K*(XK SectionII    ,Z&e %Z __ _Z %Z&e   LOCATIONOFTHECHILD: Enterwherethechildcanbelocatedatthistime.  5=   ,SectionIII    ,Z&e %Z __ _Z %Z&e   PRIORSRSINVOLVEMENT: 󀀀AsearchmustbemadeforanypriorAbuse\Neglectreportonthesamechild\family E M and\orallegedperpetratorhavingoccurredwithintwoyearsofthisreport.Enterthedatesofpreviousreportsaccepted   bySRSforfurtherassessmentandthecasefindings.       ,SectionIV U ]  Ѐ  ,Z&e %Z __ _  Z %Z&e REPORTERNAME: Enterthename,address,telephone#ofthereporterifgiven.Enter"anonymous"ifthereporter   refusestoprovidethename.Encouragethereportertoprovideinformationintheeventfurtherinformationisrequired   toconducttheinquiry. em    ,Z&e %Z*]9: dd!rr!45$$],rr+  :6666'   :  H.p x(08" hXHd    dZ %Z&e_ _ԀPracticeNote: [c   0Generally,areporterwillbemorelikelytoprovidetheirnameifallpertinentinformationaboutthesuspected " abuseorneglectisobtainedfromthempriortoaskingtheirname.Anexplanationwhytheinformationis  importantmaygivethemenoughcomforttogivetheirname._F _ԀAnexampleofwhySRSpreferstoobtainthename  mightbe: Intheeventweneedadditionalinformationfromyou."Z&e %Z<20W_  6666 < 0  K*(XFNKZ %Z&e  ,__ _Z&e %Z  Z %Z&e ADDRESS (street,city,state,andzip,phone#): SelfExplanatory.     ,  Z&e %Z  ,__ _  Z %Z&e REPORTSOURCE(RELATIONSHIP): 󀀀Checkthecategorythatmostclearlyindicatestherelationshipofthe  reportertothechildorfamilyorindicate otherandspecifytherelationship.Note:Ifthereporterindicatedthey jr wantedtobeanonymous,therelationshipcodemustbe anonymous. )1   ,Z&e %ZZ %Z&e SectionVINITIALASSESSMENTTOBECOMPLETEDBYTHESUPERVISOR/DESIGNEE   REPORTSWHICHSRSISNOTAUTHORIZEDTOACCEPTFORINVESTIGATION: 9A    , __ _Z&e %Z  Z %Z&eIndicate Yesor Noifthefollowingappliestotheinformationprovidedbyreporter: "   ,  ,__ _Z&e %Z  Z %Z&eAllegedincidenttookplaceinaninstitutionoperatedbySRSorJuvenileJustice.Entertowhomareferralwasmade 5=$ andthedate.SuchreportsaretobemadetotheAttorneyGeneral,DivisionofCriminalInvestigation,Faxto:(785) % 2913875.  &   ,;<= , Note:Areportthatachildwhoresidesinastateinstitutionissuspectedofhavingbeenabusedorneglectedwhile 1"9( onahomevisitshallbehandledbytheareasocialworkerasanyotherreport.  ")  ,  ,Z&e %Z__ _Ԁ  Z %Z&eAllegedperpetratorisanSRSor_JJA_Ԁemployee:SRSor_JJA_Ԁemployeesincludeanyemployeeofanydivisionorbranch n$v + ofSRSor_JJA_Ԁincluding,butnotlimitedto: A%I!,   ,   ` EconomicAssistanceSpecialist &".  ` SocialWorkers ~'#/  ` _CSE_Ԁstaff =(E$0  ` VocationalRehabilitationstaff (%1  ` Administrators )%2  ` Supportstaff z*&3  ` ProgramWorkers,Program_Techs_ԀandHomemakers 9+A'4   ,fRhDp Lx(T0\8"XfIfyes,thereportmustbereferredtothe APPROPRIATELOCALLAWENFORCEMENTAGENCY .Enterto W,_(6 whomareferralwasmadeandthedate.Z&e %Z -)7  ,Z %Z&eFosterparents,daycareproviders,orotherswhocontractwithSRSorJJAarenotemployees. .*9 ;<= ; <; =<h =   ,Z&e %Z__ _  Z %Z&eAllegedvictimis23orolder.Thedepartmentmayoccasionallyreceiveareportaboutapersonwhoisnowanadult,  butwasabusedorneglectedasachild.Kansasstatutesprovidethatthedepartmentmaynotinvestigatesuchreportif S theallegedvictimis23yearsofageorolderatthetimethereportisreceivedbythedepartment.IfYes,thereportmay  bereferredto ADULTSERVICESOROTHERAPPROPRIATERESOURCE .Ifareferralismade,entertowhom Q areferralwasmadeandthedate.    , SectionVI PreliminaryInquiryREQUIREDoncurrentopencasesandifanyfamilymemberorallegedperpetratorhasprior  CFSinvolvementandnofurtherCFSactionneeded. M  PRELIMINARYINQUIRY:ADDITIONALINFORMATIONNEEDEDTOMAKEINITIALASSESSMENT K   DECISION:    Z&e %Z __ _Z %Z&eԀ0  Whenasupervisordeterminesinformationavailableisinsufficienttodecideifassignmentofthecaseforfurther    assessmentisappropriate,thesupervisormay(atsupervisorsdiscretion)requestadditionalinformationtobeobtained [  withinamaximumof3workingdays.Thesupervisorwilldocumentthedate&timetherequestforadditional   informationwasmadeanddatetheinformationtobeobtained.ThisisconsideredaPreliminaryInquiryand Y  informationobtainedistoberecordedonthe1000A. $$  , NOTE:THISOPTIONSHOULDNEVERBEUSEDWHENAREPORTALLEGESACHILDMAYBEIN   IMMINENTDANGER. U  , ,   ,0  ZX[XZ Aninitialassessmentdecisionshallbemadewiththeinformationavailableattheendofthe3 S workingday_timeframe_ .9$$ #ZXZX[;#  Z&e %Z Z %Z&e SectionVIIZ&e %Z  r   XK.p x(08"h,XKZ %Z&e__ _Ԁ  WASREPORTRECEIVEDFROMLAWENFORCEMENT?: Check Yesor No.IfYes,enterthedate  thatawrittenreportwasrequestedandreceived.Ifthewrittenreporthasbeenreceivedenterthedatethereport C wasreviewed.    XB.p x(08"XB  XB.p x(08"XB__ _  ISFURTHERACTIONNEEDED?: AfterreviewoftheLawEnforcementReport,iffurtherSRSactionis  neededcheck"Yes"andcompleteformCFS1002.If"No"ischeckedexplainwhyfurtheractionisnotrequiredin ? SectionVIII,BasisforScreeningOutReport. ~    XB.p x(08"XB SectionVIII 󀀀InitialAssessmentDecision |"   XB.p x(08"XBZ&e %Z__ _Z %Z&e  AllRiskFactorslistedin_PPM_Ԁ1301havebeenreviewed?Indicatebycheckingthe YESor NObox. z$   XB.p x(08"XB ?@A XB.p x(08"XBZ&e %Z__ _Z %Z&e  Historyonallfamilymembersandallegedperpetratorshasbeenreviewedasrequiredin_PPM_Ԁ1302.Check YES  & ifthehistoryisavailableandhasbeenreviewed.Check NotRequiredifreviewofhistoryisntrequiredpriorto _!' InitialAssessment. "(   XB.p x(08"XB  XB.p x(08"XBZ&e %Z__ _Z %Z&e   IndicateifthereportisacceptedornofurtherCFSactionneeded.IftheInitialAssessmentiscompletedwithno # * furtherCFSactionneeded,indicateallofthereasonsthereportwillnotbeacceptedforfurtherassessment.If o$ + accepted,proceedtoformCFS1002. .%!,   XB.p x(08"XB      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~ B(83U""   ,B.p x(08"XB   X,  B.p x(08"XBW2_3      IncertaincircumstancesreportscanbedeterminednofurtheractionneededafterinitialACCEPTANCE.See_PPM_ &,#. 1470.WX݌ k'#/ Ќ  X XX   ALLEGEDABUSEORNEGLECTZ~ Z  (i%1 Z Z~  X_ _  Reportdoesnotmeetthestatutorydefinitionofa_CINC_Ԁor_PPM_Ԁdirectives[NSC] g*&3   XB.pp x(08"XB  B. p x(08"pXB_ _Ԁ Reportdoesnotindicatechildhasbeenharmedorislikelytobeharmed +e(5 _ _Ԁ Reportconcernscaregiverbehaviorswhichdonotdirectlyharmachildorplaceachildina ,$)6 likelihoodofharm.Z&e %Z c-)7   B.p x(08" XBZ %Z&e ".*8 ?@A ? @? A@Hh A   B. p x(08"XB_ _ Credibleinformationinthereportindicatesconcernisminimalorremote;theincidentwas ` reportedasaccidentalorasingle,minor,incident.    B.pp x(08" XB ~   B.p x(08"pXB_ _ԀReportsAllegingAbuseorNeglectinthePast. =  `  \  `  B. p x(08"XB_ _ Reportconcernschildcarelicensingonly.Referredto_K.D.H.E_     B.p x(08" XB  B. p x(08"XB_ _ Reportfailstoprovidetheinformationnecessarytolocatechild[_FPI_]  9   B.p x(08" XB  B.p x(08"XB_ _ Reportisknowntobefictitiousand/ormalicious[_FRP_]        B.p x(08"XBZ&e %Z  v    B. p x(08"XBZ %Z&e_ _ IncidenthasbeenorisbeingassessedbySRSand/orlawenforcement[_AAS_]  5    XB.p x(08" XBZ&e %Z  XB. p x(08"XBZ %Z&e_ _ SRSdoesnothaveauthoritytoproceedand/orhasaconflictofinterest[NAP]Z&e %Z '    Z %Z&e NONABUSE\NEGLECTONLY d   ""   ,B.p x(08" XB   X,  B.p x(08"XBdi2_3      Basesfornofurtheractionneededlistedaboveforabuse/neglectreportsarealsoapplicableto_CINC:NAN_Ԁreports. #  Inadditionthefollowingreasonsapplyto_CINC:NAN_Ԁreportsonly. diej݌   Ќ  X  XX    B.pp x(08" XB _ _Z&e %Z 4 Z %Z&eReportindicatesfamilyhasorwilladdressconcernsontheirown.[_FAC_]Z&e %Z `   XB.p x(08"pXBZ %Z&e  XB.pp x(08"XB_ _ 4 Reportindicatesanotheragencyhasorwilladdressconcerns[_OAC_]Z&e %Z ~   Z %Z&e  XB.p x(08"pXB BASISFORNOFURTHERCFSACTIONNEEDED: 󀀀 /   XB.p x(08"XB XB.p x(08"XBIFTHEINITIALASSESSMENTINDICATESNOFURTHERCFSACTIONISNEEDED,THISSECTION M MUSTBECOMPLETEDTOSUPPORTTHEREASONSINDICATEDABOVE.Commentsinthissection l  expandonthereasonscheckedintheprevioussection. +  X XB.p x(08"XB   X XB.p x(08"XBӀThebasisfornofurtherCFSactionneededshalladdresseachoftheallegationsinthereport,riskfactorsidentifiedif I historyisavailableforreview,addresstheimpactofhistoryonthe_deicision_Ԁandthespecificreasonsthereportwas h  notaccepted.Itisexpectedthatapersonunfamiliarwiththecasecould,byreadingthisnarrativesectionandthe '! checkmarksabove,determinethereasonthecasedidnotrequirefurtherCFSactionandwhethertherewasa " sufficientbasisforthedecision.Z&e %Z <      D  E#   XDEF XZ %Z&e Note:DOCUMENTATIONOFTHECOMPLAINTANDACTIONTAKEN(FORMSCFS1000ANDCFS 7!% 1001/1001A)AREREQUIREDTOBEKEPTONFILE.ReportswithnofurtherCFSactionneededmustbe !& keptfortwoyears.Z&e %Z  "U'  l XB.p x(08"XBZ %Z&e lSectionIX  3$)   XB.p x(08"XBZ&e %Z__ _  Z %Z&e SUPERVISORORDESIGNEESIGNATURE/DATE: ThesupervisorordesigneeMUSTsignanddatethis %Q + _form._____________________________