Form Cfs-299 - Investigation Checklist For Supervisors

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Arkansas Department of Human Services

Division of Children and Family Services

Investigation Checklist for Supervisors

Referral Name:

_____________________________ Referral Number: _________________________________

Referral Date:

______/______/______

Priority: _______

Referral Time:

_____ _____: ____ ____ am/pm

Assessor’s Name: _________________________________

Assignment Date: ______/______/______

Supervisor’s Name:

_______________________________

Allegations:

_____________________________

Report Initiation:

_____________________________

Date: ______/______/______

_____________________________

Time: _____ _____: _____ _____ am/pm

Conducted supervisory conference at time of assignment.

Yes

Attempted

Conducted CHRIS search and an out of state prior history check if the family lived in

Yes

Attempted

another state within the last five years.

Reviewed prior investigations.

Yes

Attempted

Interviewed:

Reporter

Yes

Attempted

Victim(s) interviewed (alone and outside presence of offender or observed

All

Attempted

if too young)

Some

Non-victim children (alone and outside presence of offender or observed if

All

Attempted

too young)

Some

All

Non-offending parents/caretakers

Attempted

Some

All

Other household members

Attempted

Some

All

Collateral(s)

Attempted

Some

All

Alleged offender(s) (face-to-face)

Attempted

Some

Provided and explained PUB-52.

Yes

Attempted

Completed Health and Safety Checklist and Safety Planning within 48 hours of contact

with the victim(s), excluding weekends and holidays.

Yes

Attempted

Entered contact notes into CHRIS within 48 hours of contact, excluding weekends and

Yes

Attempted

holidays.

Assessed home environment and family interactions.

Yes

Attempted

Yes

Completed Protection Plan (CFS-200), if needed.

Conducted fourteen day supervisory conference.

Yes

Attempted

Completed demo screens.

Yes

Attempted

Provided list of mental health providers to parents/guardians of victim and offender if

report involving sexual abuse was found true and alleged offender was under 18 at the

Attempted

Yes

time the act or omission occurred.

Documented provision of mental health provider list in Investigations Services Log, if

Yes

N/A

applicable (see item above).

Findings: _______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

Rationale supports final disposition and addresses items listed in narrative.

Yes

Collaterals are individuals who can provide information concerning the safety and well-being of the children, parent functioning, quality of home environment and

quality and stability of relationship between family members. Collaterals must have knowledge of the family but not have been involved in reporting maltreatment or

referring the family for services to DCFS. DCFS FSWs are considered collaterals and should be interviewed if a service case is currently opened or was closed within

the past year.

CFS-299 03/2014