Caregiver 60 and Over Checklist Instructions
This form contains 115 fields organized into 42 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Adoption Liaison/Coordinator | ||
| Adoption Liaison/Coordinator Name | Text |
Please provide the printed name of the Adoption Liaison or Coordinator. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Adoption Liaison/Coordinator Phone Number | Text |
Please provide the phone number for the Adoption Liaison or Coordinator. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Adoption/Liaison Coordinator Participation Method | ||
| by phone | Checkbox |
Check this box if the Adoption/Liaison Coordinator participated by phone. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| in person | Checkbox |
Check this box if the Adoption/Liaison Coordinator participated in person. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Agency/DCFS Region, Site and Field | ||
| Agency/DCFS Region, Site and Field | Text |
Please enter the name of the agency, the DCFS region, the site, and the specific field. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Back-up Caregiver Details | ||
| Back-up Caregiver Name | Text |
Enter the full name of the back-up caregiver. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Back-up Caregiver Date of Birth | Date |
Enter the date of birth for the back-up caregiver. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Back-up Caregiver Address | Text |
Enter the full residential address of the back-up caregiver. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Back-up Caregiver Phone Number | Text |
Enter the phone number for the back-up caregiver. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Relationship to Child | Text |
Enter the back-up caregiver's relationship to the child. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Child Agreement | Text |
Indicate if the child (if aged 4 or older) agrees to the back-up caregiver. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| CANTS/LEADS Check | ||
| CANTS/LEADS Date | Date |
Provide the date the CANTS/LEADS check was performed.
|
| CANTS/LEADS Results | Text |
Provide the results of the CANTS/LEADS check.
|
| Caregiver #1 Health Status | ||
| Caregiver #1 Health Status | Text |
Please enter the health status of Caregiver #1. Fill only if 'Caregiver age' is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Caregiver #1 Medical Evaluation Form | ||
| Caregiver 1 Evaluation Date | Date |
Enter the date the medical evaluation form for Caregiver #1 was received and reviewed. Fill only if 'Caregiver #1 Health Status' is not empty.
Depends on:
Caregiver #1 Health Status
|
| Caregiver 1 Evaluation Doctor/Clinic | Text |
Provide the name of the doctor or clinic from which Caregiver #1's medical evaluation form was received. Fill only if 'Caregiver #1 Health Status' is not empty.
Depends on:
Caregiver #1 Health Status
|
| Caregiver #2 Health Status | ||
| Caregiver #2 Health Status | Text |
Provide the health status for Caregiver #2. Fill only if 'Caregiver age' is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Caregiver #2 Medical Evaluation Form | ||
| Caregiver 2 Medical Evaluation Date | Date |
Please enter the date when Caregiver #2's medical evaluation form was received and reviewed. Fill only if 'Caregiver #2 Health Status' is not empty.
Depends on:
Caregiver #2 Health Status
|
| Caregiver 2 Medical Evaluation Clinic/Doctor | Text |
Please enter the name of the doctor or clinic that performed Caregiver #2's medical evaluation. Fill only if 'Caregiver #2 Health Status' is not empty.
Depends on:
Caregiver #2 Health Status
|
| Caregiver Relationship | ||
| Relative | Checkbox |
Check this box if the current caregiver is a relative.
|
| Non-relative | Checkbox |
Check this box if the current caregiver is not a relative.
|
| Child Centered Collaterals | ||
| Child Centered Collaterals | Text |
Please provide the names of individuals the child identifies as important, particularly for children aged 4 and older.
|
| Child's Basic Information | ||
| Child Name | Text |
Provide the full name of the child.
|
| Male | Checkbox |
Check this box if the child's gender is male.
|
| Female | Checkbox |
Check this box if the child's gender is female.
|
| Date of Birth | Date |
Enter the child's date of birth.
|
| Child ID | Text |
Enter the unique identification number for the child.
|
| Child's Contact with Biological Family | ||
| Biological Family Contact Details | Text |
Provide details about the child's contact with their biological family, including who they contact and how frequently.
|
| Child's Special Needs | ||
| Child's Special Needs | Text |
Please describe all special needs of the child.
|
| Concerns about Caregiver or Placement | ||
| GAL Concerns | Text |
Provide details about any concerns the GAL (Guardian ad Litem) has regarding the caregiver or the placement. Fill only if 'Name of current GAL' is filled
Depends on:
Current GAL Name
|
| Conference Participation | ||
| Yes | Checkbox |
Check this box if the back-up caregiver participated in the conference. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| No | Checkbox |
Check this box if the back-up caregiver did not participate in the conference. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| In Person Participations | Text |
Enter the number of times the back-up caregiver participated in the conference in person. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Telephone Participations | Text |
Enter the number of times the back-up caregiver participated in the conference by telephone. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Current Involvement of Back-up Caregiver | ||
| Yes, currently involved | Checkbox |
Check this box if the back-up caregiver is currently involved with the child. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| No, not currently involved | Checkbox |
Check this box if the back-up caregiver is not currently involved with the child. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| How Involved | Text |
Please describe how the back-up caregiver is currently involved with the child. Fill only if 'Yes, currently involved' is 'Yes'.
Depends on:
Yes, currently involved
|
| Involvement Frequency | Text |
Please provide the frequency of the back-up caregiver's involvement with the child. Fill only if 'Yes, currently involved' is 'Yes'.
Depends on:
Yes, currently involved
|
| Date Back-up Caregiver Identified | ||
| Date Identified | Date |
Provide the date when the back-up caregiver was identified. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Date of Last Conversation with GAL | ||
| Date of Last Conversation with GAL | Date |
Provide the date of the last conversation with the GAL. This date must be within 6 months of the date the checklist is submitted for review. Fill only if 'Name of current GAL' is filled
Depends on:
Current GAL Name
|
| Date of Placement | ||
| Date of Placement | Date |
Provide the date when the placement occurred.
|
| Department of Aging Services Status | ||
| Number of Services In Place | Text |
Enter the number of Department of Aging services currently in place for the caregiver or family member.
|
| Number of Services Needed | Text |
Enter the number of Department of Aging services needed for the caregiver or family member.
|
| First Caregiver Name and D.O.B. | ||
| First Caregiver Name | Text |
Enter the full name of the first caregiver.
|
| First Caregiver Date of Birth | Date |
Enter the date of birth for the first caregiver.
|
| Formal Supports | ||
| Agency Name | Text |
Please provide the name of the agency involved. Fill only if 'Formal Supports N/A Reason' is 'No'.
Depends on:
Formal Supports N/A Reason
|
| How Involved | Text |
Please describe how the agency is involved. Fill only if 'Formal Supports N/A Reason' is 'No'.
Depends on:
Formal Supports N/A Reason
|
| Formal Supports N/A Reason | Text |
Please provide a reason if formal supports are not applicable.
|
| Future Care Circumstances Review | ||
| Reviewed Circumstances | Text |
Enter a summary of the circumstances reviewed by the caseworker that may require the back-up caregiver to assume future care of the child. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Review Date | Date |
Enter the date when the caseworker reviewed the circumstances. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Others Present | Text |
Enter the names of any other individuals present during the review of circumstances. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Preparedness Details | Text |
Provide details regarding the back-up caregiver's preparedness to assume their future role. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Future Role/Responsibilities Review | ||
| Date of Review | Date |
Enter the date when the caseworker reviewed the back-up caregiver's future role and responsibilities. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Others Present | Text |
Provide the names or roles of other individuals who were present during the review of the back-up caregiver's future role and responsibilities. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Yes | Checkbox |
Check this box if the back-up caregiver is prepared to assume their future role. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| No | Checkbox |
Check this box if the back-up caregiver is not prepared to assume their future role. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| General | ||
| Text5 | Text | |
| Text6 | Text | |
| Text7 | Text | |
| Text8 | Text | |
| Text15 | Text | |
| Text16 | Text | |
| Text17 | Text | |
| Text18 | Text | |
| Text19 | Text | |
| Text20 | Text | |
| Text25 | Text | |
| Text26 | Text | |
| Text27 | Text | |
| Text44 | Text | |
| Text45 | Text | |
| Guardian ad Litem Name | ||
| Current GAL Name | Text |
Please provide the full name of the current Guardian ad Litem.
|
| Home Occupancy Information | ||
| Home Occupancy Status | Text |
Provide the current occupancy status of the home, indicating whether it is rented or owned.
|
| Occupancy Duration | Text |
Indicate the duration for which the home has been currently occupied. Fill only if 'Home Occupancy Status' is 'Yes'.
Depends on:
Home Occupancy Status
|
| Home Safety Checklist Details | ||
| Home Safety Checklist Completed | Checkbox |
Check this box if the Home Safety Checklist (CFS 2025) has been completed in accordance with Administrative Procedure #25 for an unlicensed placement. Fill only if 'Unlicensed' is 'Yes'.
Depends on:
Unlicensed
|
| Checklist Completion Date | Date |
Enter the date the Home Safety Checklist was completed. Fill only if 'Unlicensed' is 'Yes'.
Depends on:
Unlicensed
|
| Hotline Contact Information | ||
| No | Checkbox |
Check this box if the hotline has not been contacted about this child in the past 6 months.
|
| Yes | Checkbox |
Check this box if the hotline has been contacted about this child in the past 6 months.
|
| Unfounded | Checkbox |
Check this box if the hotline was contacted and the outcome was determined to be 'Unfounded'. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Indicated | Checkbox |
Check this box if the hotline was contacted and the outcome was determined to be 'Indicated'. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Outcome | Text |
Provide the outcome of the hotline contact, if applicable. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Household Income | ||
| Household Income Amount | Number |
Enter the annual or monthly household income amount. Fill only if 'Caregiver age' is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Income Verification Method | Text |
Provide details on how the household income was verified. Fill only if 'Household Income Amount' is not empty.
Depends on:
Household Income Amount
|
| Household Member Information | ||
| Other Household Members | Text |
Provide the names and ages of other individuals residing in the home and their relationship to the child.
|
| Informal Supports | ||
| Informal Support Provider | Text |
Enter the name(s) or role(s) of the individual(s) who provide informal support to the caregiver.
|
| Reason for Assistance | Text |
Explain the reason why informal support is provided to the caregiver. Fill only if 'Not Applicable' is 'No'.
Depends on:
Not Applicable
|
| Frequency of Assistance | Text |
Describe how often the informal support is provided. Fill only if 'Not Applicable' is 'No'.
Depends on:
Not Applicable
|
| Not Applicable | Text |
If informal supports are not applicable, provide a reason or mark this field accordingly.
|
| Licensing Status | ||
| Licensed | Checkbox |
Check this box if the current caregiver or placement is licensed.
|
| Unlicensed | Checkbox |
Check this box if the current caregiver or placement is unlicensed.
|
| Placement Contact Information | ||
| Placement Address | Text |
Please enter the full street address of the current placement.
|
| Placement Phone Number | Text |
Please provide the phone number associated with the current placement.
|
| Placement/Permanency Caseworker | ||
| Printed Name | Text |
Please enter the printed name of the Placement/Permanency Caseworker. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Phone Number | Text |
Please provide the phone number of the Placement/Permanency Caseworker. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Placement/Permanency Supervisor | ||
| Supervisor Printed Name | Text |
Please provide the printed full name of the Placement/Permanency Supervisor. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Supervisor Phone Number | Text |
Please provide the phone number of the Placement/Permanency Supervisor. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Provided Services | ||
| Homemaker Services Details | Text |
Please provide details regarding homemaker services.
|
| Meals on Wheels Details | Text |
Please provide details regarding Meals on Wheels services.
|
| Transportation Assistance Details | Text |
Please provide details regarding transportation assistance services.
|
| Respite Services Details | Text |
Please provide details regarding respite services.
|
| Other Services Details | Text |
Please provide details regarding any other services provided.
|
| Reviewer's Assessment | ||
| Has Concerns | Checkbox |
Check this box if the reviewer has concerns regarding the answers reviewed. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Concerns: Living Arrangement | Checkbox |
Check this box if the reviewer's concerns are specifically about the living arrangement (e.g., housing, finances, health, safety). Fill only if 'Has Concerns' is 'Yes'.
Depends on:
Has Concerns
|
| Concerns: Back-up Plan | Checkbox |
Check this box if the reviewer's concerns are specifically about the back-up plan. Fill only if 'Has Concerns' is 'Yes'.
Depends on:
Has Concerns
|
| Satisfied with Plans | Checkbox |
Check this box if the reviewer is satisfied that appropriate plans, including a back-up plan, have been made for the child. Fill only if 'Caregiver's D.O.B.' indicates age is 60 or older
Depends on:
First Caregiver Date of Birth, Second Caregiver's Date of Birth
|
| Second Caregiver Name and D.O.B. | ||
| Second Caregiver's Name | Text |
Please provide the full name of the second caregiver.
|
| Second Caregiver's Date of Birth | Date |
Please provide the date of birth for the second caregiver.
|
| Service Recipient | ||
| Caregiver Services | Text |
Provide details on the Department of Aging services that are in place or needed for the caregiver(s).
|
| Other Family Member Services | Text |
Provide details on the Department of Aging services that are in place or needed for other family members. Fill only if 'Caregiver Services' is 'No'.
Depends on:
Caregiver Services
|
| Services for the Child | ||
| Services Currently In Place | Text |
Enter any services currently in place for the child.
|
| Counseling Services | Text |
Enter details about counseling services provided for the child.
|
| Occupational Therapy Services | Text |
Enter details about occupational therapy services provided for the child.
|
| Physical Therapy Services | Text |
Enter details about physical therapy services provided for the child.
|
| Respite Services | Text |
Enter details about respite services provided for the child.
|
| Other Services | Text |
Enter details about any other services provided for the child not listed above.
|