SECTION I: IDENTIFYING INFORMATION Current Date: Month/Year of Screenings: CFC Submitting Form: Name of Screening Agency: Type of Program/Entity: Zip Code of Locations of Screenings: Screening Tool(s) used: Contact Person’s Name: Phone Number: Address: If the screening was part of a shared screening event, please check the following box: SECTION II: SCREENING INFORMATION Report Totals Total Age 0-11 Age 12-23 Age 24-35 Age 36-47 Age 48-60 Age 61+ Not Children Total Referred months months months months months months Referred Screened Screenings of Children involved with DCFS # of Children in Intact Family Services # of Children of Teen Wards Screened # of Children in Foster Care Screened Screened SECTION III: SCREENING RESULTS REFERRAL COUNTS – Report Totals for Children Ages 0 35 Months – # Referred # Referred # Referred # Referred # Referred # Referred # Referred to # Referred to # Referred to EI to LEA to EHS to PI to Child Care to HV Other Multiple for Rescreening (ECSE) Program Services Services Report Totals for Children Ages 36 60 Months – # Referred # Referred # Referred # Referred # Referred # Referred # Referred to # Referred for to LEA (ECSE) to PFA to HS to Child Care to HV to Other Multiple Rescreening Program Services Services Please fax or email completed form(s) by to your local Child and Family Connections (CFC) office at the (insert timeframe) following contact information: . You may find your local CFC office by going to the Illinois Department of Human Services office locator at . If you have questions regarding this form, please contact the Child Find Project at 1-800-851-6197.
SECTION I: IDENTIFYING INFORMATION Current Date: Month/Year of Screenings: CFC Submitting Form: Name of Screening Agency: Type of Program/Entity: Zip Code of Locations of Screenings: Screening Tool(s) used: Contact Person’s Name: Phone Number: Address: If the screening was part of a shared screening event, please check the following box: SECTION II: SCREENING INFORMATION Report Totals Total Children Screened Age 0-11 months Age 12-23 months Age 24-35 months Age 36-47 months Age 48-60 months Age 61+ months Not Referred Total Referred Screenings of Children involved with DCFS # of Children in Intact Family Services Screened # of Children of Teen Wards Screened # of Children in Foster Care Screened SECTION III: SCREENING RESULTS – REFERRAL COUNTS Report Totals for Children Ages 0 – 35 Months # Referred to EI # Referred to LEA (ECSE) # Referred to EHS # Referred to PI # Referred to Child Care Program # Referred to HV # Referred to Other Services # Referred to Multiple Services # Referred for Rescreening Report Totals for Children Ages 36 – 60 Months # Referred to LEA (ECSE) # Referred to PFA # Referred to HS # Referred to Child Care Program # Referred to HV # Referred to Other Services # Referred to Multiple Services # Referred for Rescreening Please fax or email completed form(s) by (insert timeframe) to your local Child and Family Connections (CFC) office at the following contact information: . You may find your local CFC office by going to the Illinois Department of Human Services office locator at . If you have questions regarding this form, please contact the Child Find Project at 1-800-851-6197.