Drug Endangered Children Collaboration Assessment Form
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1. Drug Endangered Children Collaboration Assessment

Please enter the following information below regarding coming into contact with a drug endangered child and any collaborations made with other community resources on behalf of the child.

All fields are optional with the exception of the reporting source. Please include as much of the information as is possible, especially in the assessment of the collaboration itself and recommendations for the future.

1. Date

	MM		DD		YYYY
Date	Date Date Month	/	Day	/	Year

2. County

County

3. Zip Code (or general location if unknown):

Zip Code (or general location if unknown):

4. Classification

Classification Criminal

Non-Criminal

Description

5. Children:

Children: How many total?
Number of female children?
Number of male children?

6. Gender and Ages of Children

	Gender	Age
Child 1	Gender and Ages of Children Child 1 Gender	Age
Child 2	Child 2 Gender	Age
Child 3	Child 3 Gender	Age
Child 4	Child 4 Gender	Age
Child 5	Child 5 Gender	Age
Child 6	Child 6 Gender	Age
Child 7	Child 7 Gender	Age
Child 8	Child 8 Gender	Age
Child 9	Child 9 Gender	Age
Child 10	Child 10 Gender	Age

If more than 10 children, put information below

7. Incident Synopsis (if possible):

Incident Synopsis (if possible):

*
8. REPORTING DONE BY:

REPORTING DONE BY: Law Enforcement Social Services Medical Treatment Prevention Prosecution Corrections Fire Department or EMT	Early Childhood Intervention Educators or School Administration Child Advocacy Foster Care Parent or Caregiver Juvenile Probation Community Coalition Other
Description

9. COLLABORATED WITH (choose ALL applicable):

COLLABORATED WITH (choose ALL applicable): Law Enforcement Social Services Medical Treatment Prevention Prosecution Corrections Fire Department or EMT	Early Childhood Intervention Educators or School Administration Child Advocacy Foster Care Parent or Caregiver Juvenile Probation Community Coalition Other
Description

10. Collaboration Synopsis (if applicable):

Collaboration Synopsis (if applicable):

11. Perceived Positives:

Perceived Positives:

12. Perceived Negatives:

Perceived Negatives:

13. Recommendations:

Recommendations:

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Drug Endangered Children Collaboration Assessment FormExit this survey