CRB CASE NOTES SHEET
Review Date: _________
Date of Last Review: _________
(Revised January 2014)
Mother: ____________________________
Child: ______________________________ Age: ________ Father: ___________________________ Status: ________
Child: ______________________________ Age: ________ Father: ___________________________ Status: ________
Child: ______________________________ Age: ________ Father: ___________________________ Status: ________
Child: ______________________________ Age: ________ Father: ___________________________ Status: ________
Attorney for Child: __________________________________ Caseworker: __________________________________
Attorney for Mother: ________________________________ CASA: _______________________________________
Attorney for Father: _________________________________ Other: ______________________________________
Case Summary (optional) ____________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please confirm the following:
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Voluntary Custody/Placement: Yes
No
Been in care since ________________ ( _____ months)
Date of Jurisdiction: __________________
Plan: ________________________________________
Basis of Jurisdiction:
Concurrent Plan: _______________________________
Mother ___________________________________________________________________________________
___________________________________________________________________________________
Father ___________________________________________________________________________________
___________________________________________________________________________________
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Indian Child Welfare Act Status of Mother: ____________________________________
Signed 1270 Form
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Indian Child Welfare Act Status of Father(s): ____________________________________
Signed 1270 Form
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____________________________________
Signed 1270 Form
We will now address placement efforts:
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1. Has DHS made
reasonable
active efforts to prevent or eliminate the need for removal of the child
from the home? (First review only. Active efforts standard if ICWA applies.)
2. Has DHS made diligent efforts to place the child with a relative or person who has a caregiver relationship?
(Applies in all cases.)