Form Rfa 802 - Compliant Intake Report Page 2
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2STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
DETAILS OF ALLEGATION(S)
COMPLETED BY RF INVESTIGATOR (PRINT NAME AND SIGN)
DATE
PRE-INVESTIGATION CONTACT WITH COMPLAINANT
POST-INVESTIGATION CONTACT WITH COMPLAINANT
DATE CONTACTED
DATE CONTACTED
PERSON CONTACTED
PERSON CONTACTED
HOW CONTACTED
HOW CONTACTED
I
I
I
I
I
I
I
I
TELEPHONE
LETTER/EMAIL
IN PERSON
N/A
TELEPHONE
LETTER/EMAIL
IN PERSON
N/A
COMMENTS
COMMENTS
LIST OF OTHER CONTACTS/REPORTS (Reports obtained for investigation, e.g. CPS, etc. Include dates.)
FOLLOW-UP/COMMENTS (e.g. legal consult date, conference date, potential administrative action, date of surrender, etc.)
RF INVESTIGATOR’S PRINTED NAME AND SIGNATURE
DATE
RF SUPERVISOR'S PRINTED NAME AND SIGNATURE
DATE APPROVED
RFA 802 (9/16) MANDATORY (CONFIDENTIAL/PUBLIC DEPENDING ON TYPE OF INFORMATION)
PAGE 2 OF 2
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