Form Rfa 811 - Confidential Names
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1STATE OF CALIFORNIA
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HEALTH AND HUMAN SERVICES AGENCY
RESOURCE FAMILY APPROVAL
CONFIDENTIAL NAMES
California Statutes and Code of Regulations require that the names of Children/Resource Families not be specified on public documents.
The following is a list of Children/Resource Families referenced in the Resource Family Visit Record identified below.
Date of Visit: _____________ Date of the RFA 809: _______________ Date RFA 809 was given to the Resource Family: _______________
RF Name: ________________________________________________________ RF ID Number: __________________________________
Name of
Date of
*Reference
Address/Location
Comment
Children/Resource Families
Birth
Number
*REFERENCE NUMBER CORRESPONDS TO THE NUMBER USED ON THE RFA 809 TO REFER TO CHILDREN/RESOURCE FAMILIES.
RF Worker’s Name(s) (Print): ____________________________________________________________ Date: ________________________
RF Worker Signature: _________________________________________________________________
RFA 811 (8/17) (CONFIDENTIAL) (OPTIONAL)
_
__________of____________pages
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