DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence INFORMATION FOR OUT-OF-HOME CARE PROVIDERS PART B – The information contained in this form must be provided to the out-of-home care provider before the prospective out-of-home Use of form: care provider agrees to placement of the child or no later than seven days after the child is placed with the out-of-home care provider. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If additional space is needed when completing this form, attach additional sheet(s). I. GENERAL INFORMATION Date Form Filled Out (mm/dd/yyyy) Out-of-Home Care Provider: Child Information A. Name Child (Full Legal) Birthdate (mm/dd/yyyy) Social Security Number – Race Ethnicity Gender Male Female Other II. PLACEMENT REASON(S) abuse or neglect (CAN) Yes No CHIPS, other than CAN Physical Type of CHIPS / JIPS / Delinquency Sexual abuse Emotional abuse Nature of Offense(s) Neglect Property Delinquent act(s) Assaultive Assaultive Placement is: Non-assaultive Voluntary Developmental needs Court ordered Medical needs Substance use Emotional needs Behavioral Life functioning needs Death, illness, or incarceration of primary caregiver Placement Reasons Specify. – III. SIGNIFICANT CONTACTS A. Legal Custodian / Guardian Name Relationship Custodian / Guardian) Address (Street, City, State, Zip Code) Telephone Number B. Guardian ad litem (GAL) and Legal Counsel Name Relationship GAL Legal Counsel Address (Street, City, State, Zip Code) Telephone Number Name Relationship GAL Legal Counsel Address (Street, City, State, Zip Code) Telephone Number C. Other Individuals / Contacts Name Relationship Type of Contact Telephone Number Name Relationship
DEPARTMENT OF CHILDREN AND FAMILIES Division of Safety and Permanence INFORMATION FOR OUT-OF-HOME CARE PROVIDERS – PART B Use of form: The information contained in this form must be provided to the out-of-home care provider before the prospective out-of-home care provider agrees to placement of the child or no later than seven days after the child is placed with the out-of-home care provider. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. If additional space is needed when completing this form, attach additional sheet(s). I. GENERAL INFORMATION Date Form Filled Out (mm/dd/yyyy) Out-of-Home Care Provider: A. Child Information Name – Child (Full Legal) Birthdate (mm/dd/yyyy) Social Security Number Race Ethnicity Gender Male Female Other II. PLACEMENT REASON(S) abuse or neglect (CAN) Physical Sexual abuse Emotional abuse Neglect Delinquent act(s) Assaultive Non-assaultive Developmental needs Medical needs Substance use Emotional needs Behavioral Life functioning needs Death, illness, or incarceration of primary caregiver Yes No CHIPS, other than CAN Type of CHIPS / JIPS / Delinquency Nature of Offense(s) Property Assaultive Placement is: Voluntary Court ordered Placement Reasons – Specify. III. SIGNIFICANT CONTACTS A. Legal Custodian / Guardian Name Relationship Custodian / Guardian) Address (Street, City, State, Zip Code) Telephone Number B. Guardian ad litem (GAL) and Legal Counsel Name Relationship GAL Legal Counsel Address (Street, City, State, Zip Code) Telephone Number Name Relationship GAL Legal Counsel Address (Street, City, State, Zip Code) Telephone Number C. Other Individuals / Contacts Name Relationship Type of Contact Telephone Number Name Relationship
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