WPCh 5VD:جmڂD)dgLLٓ2(\9RL"?Vp'zNvL5Xqsfpž񜞂WLh&L_eݣGWI*-}v{|9CjT%0q,jbŗ8` f}IhN/Zw:) NRJ5ݯ(ЮQ!jM*x8Jj8[^FTJJFUGyZ89~с>o?>P؟2?8H"1]nb |["gEںZ|"0T(9Ĺb:q5K*DXp +G+ ۷ئqd5߸l|t7!nR%ûU |%0i0YJծL61wW״p8HAP zLat>""hߤ5aoMA,6# U N % 0(UH 0P] 0D=bw4^ N mUNb?YYYYYYYYYYY 0Dpppppppp A B3333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333333fPaRSAVIN 2055DP PCL 60(9 Z 6Times New Roman RegularX($.&b AZ0Univers (W1) Regular((3/Q$ !   d   '  _hh6(#CXXCFS1004Instructions X #XMXC=#   `     h      p      x  CXXMJuly,1999#XMXC:#(3$ !  Page of &_,%3|xF, U(x-  Z6Times New Roman RegularPage of &   (3$ !   y  <<= 8C d\TABLE AC !  _Xњ 8Cdd8LXX' @  &|H%LCOMPLETINGTHEAGENCYRESPONSE,FORMCFS1004 L Ѐ@  FORFACILITYANDTHIRDPARTYREPORTS    X #L%&|H#   ItisthepolicyofthedepartmentthattheSRSresponsetoallegedchildabuseorneglectreportsshallberecordedon P formCFS1004, AgencyResponse.  Completethisformonlyforchildabuse/neglectcaseswhichoccurredina T FacilityorbyaThirdParty.    .0  CASENAME: 󀀀Usethesamecasenameasonpage1,SectionII,#1offormCFS1000.| 0(#(# .0  CASENUMBER: 󀀀Usethesamecasenumberasonpage1offormCFS1001.  (#(# .0  EVENTNUMBER: 󀀀Usethesameeventnumberasonpage1offormCFS1001.\  (#(#  X SectionI     DETERMINATIONOFCHILDSAFETY:  <  w L U  w.0  Documenttheattemptstocontactandresultsforeachallegedvictimfordeterminationofthechildssafety.` (#(# 0  ColumnA:0 (#(# listeachallegedvictimtobecontacted  (# (# 0  ColumnB:0 (#(# documentdateandtimeofeachattemptedorcompletedcontact (# (# 0  ColumnC:0 (#(# documentlocationoftheattemptedorcompletedcontact@ (# (# 0  ColumnD:0 (#(# documentwhoattempted(SW,LawEnforcement,etc.)orcompletedcontactD (# (# ^  \  U0  # U  \^ '# ColumnE:0 (#(# documentresultofattemptorcontact (# (# 0  ColumnF:0 (#(# documentdate/timesafetywasdeterminedh (# (# 0  ColumnG:0 (#(# documentifchildwas/wasnotdeterminedsafel  (# (# Ѐ $  X SectionII  PERSONSRESPONDING: Checkallthatapply.Ifotherischecked,specifybyagency(i.e.HealthDepartment) L  X SectionIII 󀀀 p   PERSONSCONTACTED/INTERVIEWED: Checkandlistbynameallpersonswhoareallegedvictims,_caregivers_, ! allegedperpetratorsandrelevantparties.Indicatethedateofcontact/interview,whetherinterviewoccurred,howthe <" interviewwasconductedandwhereresultsoftheinterviewcanbelocated.Ifanypersonlistedwasnotcontactedand/or @# interviewed,documentthereasonwhy. $  X SectionIV  h&  MEDICALSCREEN:  (Required)   ( A..0  WASMEDICALEXAMINATIONORTREATMENTRELATEDTOABUSEORNEGLECT H"* NEEDED? 󀀀Indicateifthechild(ren)wasfoundtobeinneedofurgentorimmediatemedicalattentiondue #+ totheallegedabuseorneglect.Medicalcare,asusedinthissection,shouldrelatetoinjuriesreceivedasa #l, resultofchildabuseorneglectandshouldnotbeconstruedtoincludemedicalcareortreatmentwhichis_non p$$ - u__rgent_Ԁorelective.Thisdoesnotincluderoutinemedicalconcerns.Ifansweris Yes,describeactionstaken (% . toensuremedicalcarewasprovided. Reasonableactionmeanstakingstepswhichcanbeexpectedtorelieve %!/ painandsuffering,preventfurtherharm,preventpermanentinjuryand/orpreserveevidence.Ifansweris &L"0 "No",explainwhynot.P'#1(#(# &%  U 0+< '     **ddd Xdd Xdd X(#(#,dd +   # U %&w#  PPracticeNote: |0 Ifasocialworkerdeterminesachildisinneedofamedicalexaminationortreatmentandthechild'sparentsfail 4 orrefusetoobtainamedicalexaminationthesocialworkershouldtaketheactionsareasonablepersonwouldtake  insimilarcircumstances.Thepolicyrequiringthedepartmenttoseekmedicalcareappliestomedicalneeds X resultingfromsuspectedchildabuseorneglectonly.Thedepartmentisnotresponsibletotrytomeetother \ medicalneedsofthechild(suchasimmunizationsoreyeglasses)unlesssuchneedsconstituteneglect.   Whethermedicalcareisneededisamatterofdiscretion.Whilecrookedteeth,dentalcavityornearsightedness  8  wouldnotrequirethedepartmenttoseekmedicalcare,anabscessofachildsjaworaninjurytotheeye <   threateningblindnesswouldrequiredepartmentactioniftheparentsfailedorrefusedtreatment.    NonEmergencies:Aworkermaywishtoseekadvicefromamedicalpractitionerbeforetakingnextsteps.Before d   resortingtocoercivemeasuresthecooperationofaparentshouldbesought.Anempatheticresponsetoconcerns   ofaparentaboutseekingmedicalhelpmayallowthemtobecooperative.Iftheycannotorwillnotcooperate,   apatientexplanationoftheresponsibilityofthedepartmenttoobtaintheinformationandthealternativesavailable @  shouldbemade. D  Emergencies:Ifimmediateactionisrequiredtosavealife,totreatseriousorpainfulinjuryorifactionisneeded h  topreserveevidencethatwouldotherwisebelostorunobtainable,thesocialworkershouldinitiatepromptaction. l  Thesocialworkershouldrequesttheparenttakethechildimmediatelyforexaminationortreatmentandexplain  theconsequencesoffailuretodoso. H Theassistanceofalawenforcementofficermayberequestedtotakethechildintoprotectivecustodyandtransport  thechildtomedicalcare. p InsomecircumstancesitmaybenecessarytorequesttheassistanceoftheCountyorDistrictAttorneyinobtaining , acourtorderdirectingmedicalcarebeprovided.  PaymentbySRS:Ifaparentisunwillingorunabletopayforamedicalexaminationortreatmentforachild T allegedtobeabusedorneglected:    CheckwithEconomicandEmploymentSupport(EES)todetermineifthechildhas,oriseligiblefor,amedical |0" card. 4# AuthorizepaymentifthefamilyisnoteligibleforMedicalassistance.SeeAdministrativeServicesChieffor X% furtherinformation.&%  U"\& " X # U %&# X SectionVI  ' Ѐ  !h(  SIGNATURE/DATE: 󀀀Theassignedsocialworkermustsignandenterdatecompleted.Thesupervisorshallsignand l" ) enterthedatereviewed.#w   UL#