Date: Child’s Name: CINA Case Number: Date of Gender: Male Female Federally Recognized Racial Categories: Alaska Native Native Hawaiian/Other Pacific Islander American Indian White Trial Other (Includes those reporting two or more racial categories) Black/African American Ethnicity: Hispanic or Latino Non-Hispanic or Latino Current Placement: Relative Home Residential Facility Foster Home Home Visit ______ Detention Center Placement Community: Yes No N/A Placed with Siblings: Allegations/Abuse Categories (check all that apply): Abandonment Sexual Abuse Parent Incarcerated Mental Injury/Domestic Violence Custodian Unwilling/Unable to Care Neglect Medical Neglect Substance Abuse Runaway Mental Illness: Parent Physical Harm Delinquency
Date: Child’s Name: CINA Case Number: Date of Gender: Male Female Federally Recognized Racial Categories: Alaska Native American Indian Black/African American Native Hawaiian/Other Pacific Islander White Other (Includes those reporting two or more racial categories) Ethnicity: Hispanic or Latino Non-Hispanic or Latino Current Placement: Relative Home Residential Facility Foster Home Trial Home Visit ______ Detention Center Placement Community: Placed with Siblings: Yes No N/A Allegations/Abuse Categories (check all that apply): Abandonment Parent Incarcerated Custodian Unwilling/Unable to Care Medical Neglect Runaway Physical Harm Sexual Abuse Mental Injury/Domestic Violence Neglect Substance Abuse Mental Illness: Parent Delinquency