Spokane County Head Start/ECEAP/EHS CHILD PROTECTIVE SERVICES REPORT Date To CPS Central Intake, 363-3333 (day time); 1-800-562-5624 (after hours) From HS/EHS/ECEAP Name Job title employee Site Address Re Written follow-up on a phoned CPS report Staff who made the initial CPS telephone call? Name Job title What was the CPS intake worker’s full name? What is the referral CPS risk rating of this number? report Child’s name Birth date Parent’s name Street address City St Zip Day phone Evening phone Brief description of nature of concern: Any other CPS reports previously filed? Yes No If yes, please describe the CPS report date and concerns Has this report been shared with the parent or guardian? Yes No If yes, what kind of follow-up has been discussed with the parent or guardian? What is the plan for future follow-up with the family? HS/EHS center manager’s/ECEAP director’s signature Original Copy Copy CPS Intake Child’s File Center Manager DCFS Region I (then forward to social 1313 N Atlantic St, Suite 2000 services specialist) Spokane WA
Spokane County Head Start/ECEAP/EHS CHILD PROTECTIVE SERVICES REPORT Date To CPS Central Intake, 363-3333 (day time); 1-800-562-5624 (after hours) From HS/EHS/ECEAP employee Name Job title Site Address Re Written follow-up on a phoned CPS report Staff who made the initial CPS telephone call? Name Job title What was the CPS intake worker’s full name? What is the referral number? CPS risk rating of this report Child’s name Birth date Parent’s name Street address City St Zip Day phone Evening phone Brief description of nature of concern: Any other CPS reports previously filed? Yes No If yes, please describe the CPS report date and concerns Has this report been shared with the parent or guardian? Yes No If yes, what kind of follow-up has been discussed with the parent or guardian? What is the plan for future follow-up with the family? HS/EHS center manager’s/ECEAP director’s signature Original CPS Intake DCFS Region I 1313 N Atlantic St, Suite 2000 Spokane WA Copy Child’s File Copy Center Manager (then forward to social services specialist)
ccs-97-104WORD.docx