Mississippi Case Review-CPS and Licensure Investigations of Foster Care Settings-For Rachel and Mia Survey

Mississippi Case Review-CPS and Licensure Investigations of Foster Care Settings-For Rachel and Mia

1. Section One: Facility/Home Information

Identification Information

Case Review ID:

Reviewer's name:

Intake Number:

Child ID:

	MM		DD		YYYY
Date of birth	Child's Date of Birth: Date of birth Month	/	Day	/	Year

County of Service at Time of Intake:

County of Responsibility at Time of Intake:

	MM		DD		YYYY
Date	Date of Entry into custody related to this maltreatment allegation: Date Month	/	Day	/	Year

	MM		DD		YYYY
Date	Date of Entry into this Foster Care Placement at the Time of the Allegation: Date Month	/	Day	/	Year

Child's Placement Type at the time of the alleged maltreatment:

Please enter the name of the facility or home where the child was placed at the time of the alleged maltreatment:

Name of Resource Worker at Time of Intake: Applicable, details entered below

Not Applicable

Name:

Please enter the Resource ID Number: Applicable

Not Applicable, because court ordered placement

Not Applicable, because in own home

License/MACWIS Number

Investigator's Name: