Form Soc 158a - Foster Child'S Data Record And Afdc-Fc Certification
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1STATE OF CALIFORNIA
HEALTH AND WELFARE AGENCY
DEPARTMENT OF SOCIAL SERVICES
FOSTER CHILD'S DATA RECORD AND AFDCFC CERTIFICATION
A
1. Submittal Date
2. Caseworker ID
3. Eligibility Worker ID
4. Agency Resp. 5.Sealed
6. ILP
B
1. Case Number / State ID
2. Case Number Change
3. Case Name (optional)
C
1. Child's Last Name
2. Child's First Name
3. MI
4. Date of Birth
5. Social Security Number
D
1.Adop.
2.Health
3.
4.
5. Removed from
6. Pri.
7. Sec.
8. Removed
9.
Status
Cond.
Gender
Ethnicity
Home Date
Reason
Reason
from Rel.
Name of Person from whom Child Removed
E
1.
2.
3.
Legal Authority
6. Number of Placements
Petition Date
Detention Order Date
Disposition Order Date
4. Code
5. Date
in Episode
F
1. Placement
Last End-Dated Placement
Placement Episode Termination Transferring to
Start Date
2. Reason 3. Date
4. Reason
5. Date
6. Date
7. County
8. Agency Resp.
G
1. Placement Facility Name
2. Primary Substitute Care Provider
3. SCP Relationship to Child
H
1. Child’s Street Address
2. Child’s City
3. State
4. ZIP
5. County
I
1.
2.
3.
4.
5. Specialized
6. County Funds
7. AFDC-FC
8. AFDC-FC
Facility Type
License Status
License Number
Basic Rate
Care Increment
Y/N
Effective Date
Termination Date
J
1. Payee Name
2. Payee is:
Placement Worker
Child
K
1. Payee’s Street Address
2. Payee’s City
3. State
4. ZIP
L
1. Date of Last
2. Pre-placement
3.Case Plan
4. Date of Last In-person
5. Date of Last 6-month
6.Date of Last
7. Current Service
Case Plan
Preventive Services
Goal
Contact with Child
Review Hearing
PP Hearing
Program
M
1. Child Ever
2. Child’s Age
3.
4. Year of Birth
5. Year of Birth
6. Mom’s Rights
7. Dad’s Rights
Adopted?
at Adoption
Family Structure
1st Caretaker
2nd Caretaker
Termination Date
Termination Date
FOR APPROVED HOMES:
FOR GROUP HOMES:
N
1.
This home is suited to meet the child's needs.
2.
Group home placement is necessary to meet child’s treatment needs and this facility
offers needed services.
O
1. Rationale Description
I certify that all 45-201.4 services requirements have been met and all information recorded on this form is true and correct
to the best of my knowledge.
SIGNATURE OF PLACEMENT WORKER
DATE
AGENCY
ADDRESS/LOCATION
WORKER PHONE NUMBER
CWS Case Management System
Confidential in accordance with
FOSTER CHILD'S DATA RECORD AND
SOC 158A (Rev. 02/2005)
Penal Code Section 11167.5 and/or
AFDC-FC CERTIFICATION
WIC Sections 827 and 10850
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