Adoption and Safe Families Act (ASFA) Survey Instructions
This form contains 113 fields organized into 17 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Comments | ||
| Additional Comment Line 1 | Text |
Provide the first line of any additional comments for this section.
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| Additional Comment Line 2 | Text |
Provide the second line of any additional comments for this section.
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| Additional Comment Line 3 | Text |
Provide the third line of any additional comments for this section.
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| Additional Comment Line 4 | Text |
Provide the fourth line of any additional comments for this section.
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| Additional Comment Line 5 | Text |
Provide the fifth line of any additional comments for this section.
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| Additional Comment Line 6 | Text |
Provide the sixth line of any additional comments for this section.
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| Additional Comment Line 7 | Text |
Provide the seventh line of any additional comments for this section.
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| Additional Comment Line 8 | Text |
Provide the eighth line of any additional comments for this section.
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| Additional Comment Line 9 | Text |
Provide the ninth line of any additional comments for this section.
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| Additional Comment Line 10 | Text |
Provide the tenth line of any additional comments for this section.
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| Additional Comment Line 11 | Text |
Provide the eleventh line of any additional comments for this section.
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| Additional Comment Line 12 | Text |
Provide the twelfth line of any additional comments for this section.
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| Additional Tasks or Documents | ||
| Additional Tasks or Documents List | Text |
Provide a list of any additional tasks or documents that need to be completed.
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| Additional Tasks or Documents | Text |
Provide a list of any additional tasks or documents the worker needs to complete or obtain. Fill only if 'No', 'No', 'No', 'No' is 'No', any.
Depends on:
No, No, No, No
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| AICI Confirmation Number | ||
| AICI Confirmation Number | Text |
Provide the AICI confirmation number. Fill only if 'Child Listed with AICI - Yes' is 'Yes'.
Depends on:
Child Listed with AICI - Yes
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| AICI Listing Explanation | ||
| AICI Listing Status Explanation | Text |
Provide a detailed explanation for why the child is not listed with AICI and describe the efforts currently being made to find an adoptive home for the child. Fill only if 'Child Listed with AICI - No' is 'Yes'.
Depends on:
Child Listed with AICI - No
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| Case Identification | ||
| Family ID Number | Text |
Enter the identification number assigned to the family.
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| Family RSF | Text |
Enter the RSF identifier for the family.
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| RSF | Text |
Enter the RSF identifier for the individual or case.
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| Permanency Goal | Text |
Enter the permanency goal established for the child.
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| Case Name | Text |
Enter the name associated with the case.
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| Case ID Number | Text |
Enter the identification number for the case.
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| Date of Birth | Date |
Enter the date of birth of the individual.
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| Case Information | ||
| Child's Name | Text |
Please enter the full name of the child for this case review.
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| Today's Date | Date |
Please enter today's date.
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| ID Number | Text |
Please enter the identification number for the case.
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| Case Reviewer Notes | ||
| Case Reviewer Note 1 | Text |
Please provide any relevant notes or observations from the case review.
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| Case Reviewer Note 2 | Text |
Please provide any additional relevant notes or observations from the case review.
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| Case Reviewer Note 3 | Text |
Please provide any further relevant notes or observations from the case review.
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| Caseworker and Legal Information | ||
| Primary Caseworker | Text |
Enter the name of the primary caseworker.
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| Primary Caseworker Supervisor | Text |
Enter the name of the primary caseworker's supervisor.
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| Telephone | Text |
Enter the telephone number for the caseworker or supervisor.
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| Docket Number | Text |
Enter the docket number for the case.
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| Date of Temporary Custody | Date |
Enter the date when temporary custody was established.
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| Current Legal Status | Text |
Enter the current legal status of the case or child.
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| Completion Date | ||
| Form Completion Date | Date |
Please provide the date when this form was completed.
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| Efforts to Find Adoptive Home Description | ||
| Efforts to Find Adoptive Home Description | Text |
Provide a detailed description of the efforts being made to find an adoptive home for the child. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
|
| General | ||
| In foster care for 15 of 22 months - Yes | Checkbox |
Check this box if the child has been in foster care for 15 of the most recent 22 months.
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| In foster care for 15 of 22 months - No | Checkbox |
Check this box if the child has not been in foster care for 15 of the most recent 22 months.
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| Child under two abandoned - Yes | Checkbox |
Check this box if the child is under the age of two years and was determined at an adjudicatory hearing to be abandoned. Fill only if 'In foster care for 15 of 22 months - No' is 'No'.
Depends on:
In foster care for 15 of 22 months - No
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| Child under two abandoned - No | Checkbox |
Check this box if the child is not under the age of two years and determined to be abandoned, or if they are but were not determined to be abandoned at an adjudicatory hearing. Fill only if 'In foster care for 15 of 22 months - No' is 'No'.
Depends on:
In foster care for 15 of 22 months - No
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| Parent criminally convicted - Yes | Checkbox |
Check this box if the child's parent has been criminally convicted of murder of another child of the parent or voluntary manslaughter of another child of the parent. Fill only if 'Child under two abandoned - No' is 'No'.
Depends on:
Child under two abandoned - No
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| Parent criminally convicted - No | Checkbox |
Check this box if the child's parent has not been criminally convicted of murder of another child of the parent or voluntary manslaughter of another child of the parent. Fill only if 'Child under two abandoned - No' is 'No'.
Depends on:
Child under two abandoned - No
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| HMR | Checkbox |
Check this box if the child is currently in the care of relatives, whether licensed or unlicensed. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
|
| RET | Checkbox |
Check this box if there is a permanency goal of return home for the child. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| return home within five months | Checkbox |
Check this box if the child's permanency goal is to return home within five months. Fill only if 'RET' is 'Yes'.
Depends on:
RET
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| return home within one year | Checkbox |
Check this box if the child's permanency goal is to return home within one year. Fill only if 'RET' is 'Yes'.
Depends on:
RET
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| return home - status pending | Checkbox |
Check this box if the child's permanency goal to return home has a status pending, as ordered by the court after January 1, 1998. Fill only if 'RET' is 'Yes'.
Depends on:
RET
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| SGH | Checkbox |
Check this box if there is a permanency goal of guardianship that is expected to be achieved within 12 months for the child. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| IND | Checkbox |
Check this box if there is a permanency goal of independence that is expected to be achieved within 12 months for the child. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| AGE | Checkbox |
Check this box if the child is age 18 or over. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| CON | Checkbox |
Check this box if the child is age 14 or over and will not consent to be adopted. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| RJ1 | Checkbox |
Check this box if, within the past six months, the case was rejected at legal pre-screening (Cook County only) or screening due to lack of grounds for termination of parental rights or requiring more time to meet statutory grounds. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| RJ2 | Checkbox |
Check this box if the State's Attorney has, within the last six months, rejected a petition to terminate parental rights based on the child's best interests. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| OTH | Checkbox |
Check this box if adoption has been ruled out for another compelling reason, such as the child's mental health problems making a placement change traumatic, as documented and approved by relevant authorities. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
|
| CLO | Checkbox |
Check this box if the child's case is closed. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| ARR | Checkbox |
Check this box if the Department has adoptive rights for the child. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| HMP | Checkbox |
Check this box if the child is currently living in the home of a parent. Fill only if 'any of the questions in section 1' is 'Yes'
Depends on:
In foster care for 15 of 22 months - Yes, Child under two abandoned - Yes, Parent criminally convicted - Yes
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| ILO | Checkbox |
Check this box if the child is currently placed in an independent living arrangement (ILO).
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| Screened for TPR - Yes | Checkbox |
Check this box if the case has been screened to determine the appropriateness for filing a TPR petition, and include the pre-screening and screening dates. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Screened for TPR - No | Checkbox |
Check this box if the case has not been screened to determine the appropriateness for filing a TPR petition, and explain why not. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Text38 | Text | |
| Text39 | Text | |
| Text40 | Text | |
| Minor in Identified Adoptive Placement - Yes | Checkbox |
Check this box if the minor is placed in an identified adoptive placement after the case has passed legal screening. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Minor in Identified Adoptive Placement - No | Checkbox |
Check this box if the minor is not placed in an identified adoptive placement after the case has passed legal screening. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Adoptive Placement Identified - Yes | Checkbox |
Check this box if an adoptive placement has been identified for the minor, assuming the minor is not currently placed in an identified adoptive placement. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Adoptive Placement Identified - No | Checkbox |
Check this box if an adoptive placement has not been identified for the minor, assuming the minor is not currently placed in an identified adoptive placement. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Child Listed with AICI - Yes | Checkbox |
Check this box if the child is listed with AICI, assuming an adoptive placement has not been identified for the minor, and include the AICI confirmation number. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Child Listed with AICI - No | Checkbox |
Check this box if the child is not listed with AICI, assuming an adoptive placement has not been identified for the minor, and explain why not. Fill only if 'Reason Code' is not checked
Depends on:
HMR, RET, SGH, IND, AGE, CON, RJ1, RJ2, OTH, CLO, ARR, HMP
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| Text45 | Text | |
| Text46 | Text | |
| Text47 | Text | |
| Text48 | Text | |
| Text49 | Text | |
| Text50 | Text | |
| Yes | Checkbox |
Check this box if a TPR petition has been filed for this case. Fill only if 'has this case been screened to determine the appropriateness for filing a TPR petition?' is 'Yes'.
Depends on:
Screened for TPR - Yes
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| No | Checkbox |
Check this box if a TPR petition has not been filed for this case. Fill only if 'has this case been screened to determine the appropriateness for filing a TPR petition?' is 'Yes'.
Depends on:
Screened for TPR - Yes
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| Text53 | Text | |
| Text54 | Text | |
| Text55 | Text | |
| Text56 | Text | |
| Text57 | Text | |
| Text58 | Text | |
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| Text60 | Text | |
| Text61 | Text | |
| Yes | Checkbox |
Check this box if the worker brought a completed Adoption and Safe Families Act Survey to the administrative case review.
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| No | Checkbox |
Check this box if the worker did not bring a completed Adoption and Safe Families Act Survey to the administrative case review.
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| Yes | Checkbox |
Check this box if the worker brought any documents to substantiate a child being excluded from the survey.
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| No | Checkbox |
Check this box if the worker did not bring any documents to substantiate a child being excluded from the survey.
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| Yes | Checkbox |
Check this box if the worker brought the necessary documents to substantiate filing a TPR.
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| No | Checkbox |
Check this box if the worker did not bring the necessary documents to substantiate filing a TPR.
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| Yes | Checkbox |
Check this box if the service plan contains tasks and objectives necessary to prepare the case for filing a TPR petition by the next ACT.
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| No | Checkbox |
Check this box if the service plan does not contain tasks and objectives necessary to prepare the case for filing a TPR petition by the next ACT.
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| Text84 | Text | |
| Text85 | Text | |
| Text86 | Text | |
| Text87 | Text | |
| Text88 | Text | |
| Text89 | Text | |
| Text90 | Text | |
| Text91 | Text | |
| Text92 | Text | |
| Identified Adoptive Placement | ||
| Child Never Placed in Substitute Care | Checkbox |
Check this box if the child has never been placed in a substitute care placement.
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| Screening Dates | ||
| Pre-screening Date (Cook) | Date |
Please provide the pre-screening date for Cook. Fill only if 'Screened for TPR - Yes' is 'Yes'.
Depends on:
Screened for TPR - Yes
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| Screening Date (Downstate) | Date |
Please provide the screening date for Downstate. Fill only if 'Screened for TPR - Yes' is 'Yes'.
Depends on:
Screened for TPR - Yes
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| Signature Section Notes | ||
| Supporting Comments and Recommendations | Text |
Please provide any additional supporting comments or recommendations related to the case review. Fill only if 'Has a TPR petition been filed for this case?' is 'No'.
Depends on:
No
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| Supporting Comments or Recommendations | ||
| Supporting Comments and Recommendations | Text |
Enter any additional supporting comments or recommendations for the case.
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| Supporting Comments or Recommendations | Text |
Provide any additional supporting comments or recommendations, including tasks or documents the worker needs to complete or obtain. Fill only if 'Has a TPR petition been filed for this case?' is 'No'.
Depends on:
No
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| TPR Petition Filing Status | ||
| TPR Petition Filing Date | Date |
Provide the date the TPR petition was filed. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
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| TPR Petition Status Explanation | Text |
Explain the reason if no TPR petition has been filed, or provide any additional supporting comments and recommendations. Fill only if 'No' is 'Yes'.
Depends on:
No
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| TPR Petition Screening Explanation | ||
| Explanation for Not Screening | Text |
Provide a detailed explanation for why the case has not been screened to determine the appropriateness for filing a TPR petition. Fill only if 'Screened for TPR - No' is 'Yes'.
Depends on:
Screened for TPR - No
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