DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence ICPC Supervision Report Use of form: This form is required to be completed by the receiving entity to Wisconsin ICPC office at least quarterly. Instructions: The worker may use information from case notes, but must provide a thorough summary and assessment of the placement in each question. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. IDENTIFYING INFORMATION Name Child(ren) Date Child(ren) Placed in Home (mm/dd/yyyy) – eWiSACWIS Case ID Name Placement Resource Relationship to Child(ren)—Placement Resource – Name Current Worker Agency Name Current Worker – – Date Worker Assigned for Supervision (mm/dd/yyyy) Email Address Current Worker Telephone number Current Worker – – SUPERVISION REPORT DETAILS Time period covered under this report (dates): Provide any background information relevant to this supervision report: Provide the dates and a summary of the face-to-face contacts with the child(ren) during this reporting period, including who was present for each visit (may be taken from case notes): Describe the current physical and mental health of the child(ren) and provide updates on any medical concerns (attach records, evaluations, therapy reports, if applicable): Describe the (attach copies of report card, IEP, evaluations, if applicable): child(ren)’s educational needs Describe any concerns regarding the placement to provide financially for the child(ren): resource’s ability Describe the current status of the frequency and quality of family contact: child(ren)’s Provide information on collateral contacts (including contacts with the in the sending state) made during this reporting child’s caseworker period, if not addressed elsewhere in this report: Describe any unmet needs of the child(ren) or placement resource and any recommendations to meet those needs: Provide your assessment of general functioning and placement adjustment of both the child and placement resource: Provide your recommendation on the placement based on this supervision report: child(ren)’s Continue placement Establish guardianship Return custody to parent, terminate jurisdiction Concur with terminating jurisdiction Finalize adoption Other Specify: – Please note any questions or concerns you have for the Sending State: Please document the justification(s) for the selected Recommendation(s) for all the child(ren) above:
DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence ICPC Supervision Report Use of form: This form is required to be completed by the receiving entity to Wisconsin ICPC office at least quarterly. Instructions: The worker may use information from case notes, but must provide a thorough summary and assessment of the placement in each question. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. IDENTIFYING INFORMATION Name – Child(ren) Date Child(ren) Placed in Home (mm/dd/yyyy) eWiSACWIS Case ID Name – Placement Resource Relationship to Child(ren)—Placement Resource Name – Current Worker Agency Name – Current Worker Date Worker Assigned for Supervision (mm/dd/yyyy) Email Address – Current Worker Telephone number – Current Worker SUPERVISION REPORT DETAILS Time period covered under this report (dates): Provide any background information relevant to this supervision report: Provide the dates and a summary of the face-to-face contacts with the child(ren) during this reporting period, including who was present for each visit (may be taken from case notes): Describe the current physical and mental health of the child(ren) and provide updates on any medical concerns (attach records, evaluations, therapy reports, if applicable): Describe the child(ren)’s educational needs (attach copies of report card, IEP, evaluations, if applicable): Describe any concerns regarding the placement resource’s ability to provide financially for the child(ren): Describe the current status of the child(ren)’s frequency and quality of family contact: Provide information on collateral contacts (including contacts with the child’s caseworker in the sending state) made during this reporting period, if not addressed elsewhere in this report: Describe any unmet needs of the child(ren) or placement resource and any recommendations to meet those needs: Provide your assessment of general functioning and placement adjustment of both the child and placement resource: Provide your recommendation on the child(ren)’s placement based on this supervision report: Continue placement Establish guardianship Return custody to parent, terminate jurisdiction Concur with terminating jurisdiction Finalize adoption Other – Specify: Please note any questions or concerns you have for the Sending State: Please document the justification(s) for the selected Recommendation(s) for all the child(ren) above:
2336.docx