Form Soc 886 - Social Worker Disclosure Report

Download a blank fillable Form Soc 886 - Social Worker Disclosure Report in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Soc 886 - Social Worker Disclosure Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

STATE OF CALIFORNIA - HEALTH AHD HUMAN SERVICES AGENCY
CHILDREN AND FAMILY SERVICES DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
OUTCOMES AND ACCOUNTABILITY BUREAU
SOCIAL WORKER DISCLOSURE REPORT
Today’s Date:
Date of Incident:
Report ID Number:
REPORTER INFORMATION
Last Name:
First:
Position:
Reporter Contact Information:
Phone Number:
May we contact you to follow up on
Do you consent to disclosure of
report?
your identity?
I
I
I
I
Yes
No
Yes
No
INCIDENT AND AGENCY INFORMATION
County:
Agency Name:
Phone Number:
Agency Address:
Type of Concern
Endangers the Health or Well-being of a child
Contrary to statute/regulation
Contrary to Public Policy
Describe the child welfare policy, procedure, or practice you are concerned about:
Is this concern related to a specific case?
If yes, provide name or child identifying information:
Case or Referral ID (CWS):
I
I
Yes
No
Case Open?
Type of Case:
Child’s Location:
ER
FM
FR
PP
ST
Yes
No
If yes, provide additional information:
Is there immediate child safety involved?
Yes
No
Contact Information:
Have you reported this concern to the agency?
If yes, list the parties notified:
I
I
Yes
No
Was any action taken?
If so, describe action taken:
I
I
Yes
No
ACKNOWLEDGEMENT
The above information is true to the best of my knowledge. I understand that unless I consent to disclosure, my identity will not be disclosed by the
California Department of Social Services pursuant to Welfare & Institutions Code Section 10605.5 (a) (2) unless there is an immediate health and
safety risk to a child.
SOC 886 (12/15)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go