REQUIRED CENTRAL STAFFING INFORMATION Use of form: This form is used to provide information so that placement decisions for children in need of out-of-home care placement can be made. Personally identifiable information is used only for that purpose. The Social Security Number is not mandatory, but may be needed to obtain a temporary medical card. Instructions: A cover page summary describing the child and what the that may necessitate placement into a higher level child’s needs are of care must be attached. Name Case Manager Region Telephone Number – Name Case Telephone Number – Manager’s Supervisor Ongoing IA Other Specify: – Date Current Staffing Date Central Staffing Form Completed – – Date Internal Staffing Approval Signature From Program Manager Date Target Date for Placement – – Provide statement of expected outcomes from higher level of care agency. child’s needs and Physical / Medical Information Name Child Birthdate Age Social Security Number – Gender Ethnicity Height Approximate Weight Approximate – – Current Medication(s) and Dosage Specify: – Name Prescribing Physician – Significant Medical Conditions Specify: – Physical Limitations Specify: – Allergies Specify: – Yes No Child has Asthma Name Telephone Number Date Last Physical Exam – Child’s Pediatrician – Yes No Is child current on immunizations? child needs Specify: If “No”, immunizations – Date TB test Results of TB test – Current Placement (Status) Own home Kinship relative Licensed relative Foster care Treatment foster care Hospital Group care RCCCY Name Assessment center: – Name Stabilization center: – Name Assessment home: – Name Other Specify: – – Date Placed in current placement: – Name Current placement: – Address Current placement: – Telephone Number Current placement: – If child is not in own home, what date was the child removed from their home? Reason child was removed from home Specify: – Date Last CST: Date Next scheduled CST: – – Permanency Plan
REQUIRED CENTRAL STAFFING INFORMATION Use of form: This form is used to provide information so that placement decisions for children in need of out-of-home care placement can be made. Personally identifiable information is used only for that purpose. The Social Security Number is not mandatory, but may be needed to obtain a temporary medical card. Instructions: A cover page summary describing the child and what the child’s needs are that may necessitate placement into a higher level of care must be attached. Name – Case Manager Region Telephone Number Name – Case Manager’s Supervisor Telephone Number Ongoing IA Other – Specify: Date – Current Staffing Date – Central Staffing Form Completed Date – Internal Staffing Approval Signature From Program Manager Date – Target Date for Placement Provide statement of child’s needs and expected outcomes from higher level of care agency. Physical / Medical Information Name – Child Birthdate Age Social Security Number Gender Ethnicity Height – Approximate Weight – Approximate Current Medication(s) and Dosage – Specify: Name – Prescribing Physician Significant Medical Conditions – Specify: Physical Limitations – Specify: Allergies – Specify: Yes No Child has Asthma Name – Child’s Pediatrician Telephone Number Date – Last Physical Exam Yes No Is child current on immunizations? If “No”, immunizations child needs – Specify: Date – TB test Results of TB test Current Placement (Status) Own home Kinship relative Licensed relative Foster care Treatment foster care Hospital Group care RCCCY Name – Assessment center: Name – Stabilization center: Name – Assessment home: Name – Other – Specify: Date – Placed in current placement: Name – Current placement: Address – Current placement: Telephone Number – Current placement: If child is not in own home, what date was the child removed from their home? Reason child was removed from home – Specify: Date – Last CST: Date – Next scheduled CST: Permanency Plan
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