Form 2085-B, Child Protective Services - Bed Hold Request Instructions

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This form contains 117 fields organized into 41 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name Type Description
Caseworker Information
Caseworker ID Text
Enter the identification number for the caseworker.
Rate Group (RG) Text
Enter the rate group code for the caseworker.
Staffing Intensity (SI) Text
Enter the staffing intensity code for the caseworker.
Funding Days (FD) Text
Enter the number of funding days for the caseworker.
Child Information
No Intent to Return Checkbox
Check this box if, based on the staffing results, there is no intent for the child to return.
Child Name
Child Name Text
Please enter the full name of the child.
Date of Absence
Absence Month Number
Enter the month of the absence.
Max length: 2 characters
Absence Day Number
Enter the day of the absence.
Max length: 2 characters
Absence Year Number
Enter the year of the absence.
Max length: 4 characters
Initial Bed Hold Episode Checkbox
Check this box if the request period for the bed hold is for an initial bed hold episode.
Day 1 Activities
Day 1 Activity 1 Text
Please provide the first activity for Day 1.
Day 1 Activity 2 Text
Please provide the second activity for Day 1.
Day 1 Activity 3 Text
Please provide the third activity for Day 1.
Day 10 Activities
Day 10 Activity 1 Text
Please provide the details for the first activity on Day 10.
Day 10 Activity 2 Text
Please provide the details for the second activity on Day 10.
Day 10 Activity 3 Text
Please provide the details for the third activity on Day 10.
Day 11 Activities
Day 11 Activity 1 Text
Provide a description of the first activity for Day 11.
Day 11 Activity 2 Text
Provide a description of the second activity for Day 11.
Day 11 Activity 3 Text
Provide a description of the third activity for Day 11.
Day 12 Activities
Day 12 First Activity Text
Please enter the first activity that occurred on Day 12.
Day 12 Second Activity Text
Please enter the second activity that occurred on Day 12.
Day 12 Third Activity Text
Please enter the third activity that occurred on Day 12.
Day 13 Activities
Day 13 Activity 1 Text
Please provide the first activity or event that occurred on Day 13.
Day 13 Activity 2 Text
Please provide the second activity or event that occurred on Day 13.
Day 13 Activity 3 Text
Please provide the third activity or event that occurred on Day 13.
Day 14 Activities
Day 14 Activity 1 Text
Please provide the first activity or detail for Day 14.
Day 14 Activity 2 Text
Please provide the second activity or detail for Day 14.
Day 14 Activity 3 Text
Please provide the third activity or detail for Day 14.
Day 15 Activities
Day 15 Activity 1 Text
Provide the first activity performed on Day 15.
Day 15 Activity 2 Text
Provide the second activity performed on Day 15.
Day 15 Activity 3 Text
Provide the third activity performed on Day 15.
Day 16 Activities
Day 16 Activity 1 Services Text
Enter the number of services provided for the first activity on Day 16.
Day 16 Activity 2 Services Text
Enter the number of services provided for the second activity on Day 16.
Day 16 Activity 3 Services Text
Enter the number of services provided for the third activity on Day 16.
Day 17 Activities
Day 17 Activity 1 Text
Please provide details for the first activity on Day 17.
Day 17 Activity 2 Text
Please provide details for the second activity on Day 17.
Day 17 Activity 3 Text
Please provide details for the third activity on Day 17.
Day 18 Activities
Day 18 Activity 1 Text
Enter the first activity that occurred on Day 18.
Day 18 Activity 2 Text
Enter the second activity that occurred on Day 18.
Day 18 Activity 3 Text
Enter the third activity that occurred on Day 18.
Day 19 Activities
Day 19 Activity 1 Text
Please provide the details of the first activity for Day 19.
Day 19 Activity 2 Text
Please provide the details of the second activity for Day 19.
Day 19 Activity 3 Text
Please provide the details of the third activity for Day 19.
Day 2 Activities
Day 2 Activity 1 Text
Provide the first activity for Day 2.
Day 2 Activity 2 Text
Provide the second activity for Day 2.
Day 2 Activity 3 Text
Provide the third activity for Day 2.
Day 20 Activities
Day 20 Activity First Entry Text
Provide details for the first activity or event that occurred on Day 20.
Day 20 Activity Second Entry Text
Provide details for the second activity or event that occurred on Day 20.
Day 20 Activity Third Entry Text
Provide details for the third activity or event that occurred on Day 20.
Day 21 Activities
Day 21 Activity 1 Text
Provide the first activity for Day 21.
Day 21 Activity 2 Text
Provide the second activity for Day 21.
Day 21 Activity 3 Text
Provide the third activity for Day 21.
Day 22 Activities
Day 22 Activity 1 Text
Please enter the first activity for Day 22.
Day 22 Activity 2 Text
Please enter the second activity for Day 22.
Day 22 Activity 3 Text
Please enter the third activity for Day 22.
Day 23 Activities
Day 23 Activity 1 Text
Please provide the first activity for Day 23.
Day 23 Activity 2 Text
Please provide the second activity for Day 23.
Day 23 Activity 3 Text
Please provide the third activity for Day 23.
Day 24 Activities
Day 24 Activity 1 Number
Enter the number of services provided for Day 24, activity 1.
Day 24 Activity 2 Number
Enter the number of services provided for Day 24, activity 2.
Day 24 Activity 3 Number
Enter the number of services provided for Day 24, activity 3.
Day 25 Activities
Day 25 Activity 1 Text
Provide the details for the first activity of Day 25.
Day 25 Activity 2 Text
Provide the details for the second activity of Day 25.
Day 25 Activity 3 Text
Provide the details for the third activity of Day 25.
Day 26 Activities
Day 26 Activity 1 Text
Please provide the first activity for Day 26.
Day 26 Activity 2 Text
Please provide the second activity for Day 26.
Day 26 Activity 3 Text
Please provide the third activity for Day 26.
Day 27 Activities
Day 27 Activity 1 Text
Please provide a description of the first activity or observation for Day 27.
Day 27 Activity 2 Text
Please provide a description of the second activity or observation for Day 27.
Day 27 Activity 3 Text
Please provide a description of the third activity or observation for Day 27.
Day 28 Activities
Day 28 Activity 1 Text
Please enter the first activity for Day 28.
Day 28 Activity 2 Text
Please enter the second activity for Day 28.
Day 28 Activity 3 Text
Please enter the third activity for Day 28.
Day 29 Activities
Day 29 Activity 1 Text
Provide the first activity for Day 29.
Day 29 Activity 2 Text
Provide the second activity for Day 29.
Day 29 Activity 3 Text
Provide the third activity for Day 29.
Day 3 Activities
Day 3 Activity 1 Text
Please provide the first activity or event that occurred on Day 3.
Day 3 Activity 2 Text
Please provide the second activity or event that occurred on Day 3.
Day 3 Activity 3 Text
Please provide the third activity or event that occurred on Day 3.
Day 30 Activities
Day 30 Activity 1 Text
Please provide the details of the first activity for Day 30.
Day 30 Activity 2 Text
Please provide the details of the second activity for Day 30.
Day 30 Activity 3 Text
Please provide the details of the third activity for Day 30.
Day 4 Activities
Day 4 Activity 1 Text
Please provide the first activity that occurred on Day 4.
Day 4 Activity 2 Text
Please provide the second activity that occurred on Day 4.
Day 4 Activity 3 Text
Please provide the third activity that occurred on Day 4.
Day 5 Activities
Day 5 First Activity Text
Please provide the first activity planned or conducted for Day 5.
Day 5 Second Activity Text
Please provide the second activity planned or conducted for Day 5.
Day 5 Third Activity Text
Please provide the third activity planned or conducted for Day 5.
Day 6 Activities
Day 6 Activity 1 Text
Provide a description of the first activity for Day 6.
Day 6 Activity 2 Text
Provide a description of the second activity for Day 6.
Day 6 Activity 3 Text
Provide a description of the third activity for Day 6.
Day 7 Activities
Day 7 Activity 1 Text
Please enter the first activity performed on Day 7.
Day 7 Activity 2 Text
Please enter the second activity performed on Day 7.
Day 7 Activity 3 Text
Please enter the third activity performed on Day 7.
Day 8 Activities
Day 8 Activity 1 Number
Enter the number of the first service provided on Day 8.
Day 8 Activity 2 Number
Enter the number of the second service provided on Day 8.
Day 8 Activity 3 Number
Enter the number of the third service provided on Day 8.
Day 9 Activities
Day 9 First Activity Text
Please enter the first activity that occurred on Day 9.
Day 9 Second Activity Text
Please enter the second activity that occurred on Day 9.
Day 9 Third Activity Text
Please enter the third activity that occurred on Day 9.
I.D. No.
ID Number Text
Please enter the identification number associated with the child.
Provider Name
Provider Name Text
Please enter the full name of the service provider.
Provider No.
Provider Number Text
Please enter the provider's identification number.
Request Period
Consecutive Approved Bed Hold Episode Checkbox
Check this box if the request is for a consecutive approved bed hold episode.
Check Box6 CheckBox
Staffing Held Date
Staffing Held Date - Month Number
Enter the month the staffing was held.
Max length: 2 characters
Staffing Held Date - Day Number
Enter the day of the month the staffing was held.
Max length: 2 characters
Staffing Held Date - Year Number
Enter the year the staffing was held.
Max length: 4 characters
Supervisor Information
Supervisor ID Text
Provide the unique identification number for the supervisor. Fill only if 'Check Box18' is 'Yes'.
Depends on: Check Box18
Supervisor RG Value Text
Enter the RG value associated with the supervisor. Fill only if 'Check Box18' is 'Yes'.
Depends on: Check Box18
Supervisor SI Value Text
Enter the SI value associated with the supervisor. Fill only if 'Check Box18' is 'Yes'.
Depends on: Check Box18
Supervisor FD Value Text
Enter the FD value associated with the supervisor. Fill only if 'Check Box18' is 'Yes'.
Depends on: Check Box18
Type of Absence
Detention Checkbox
Check this box if the child's absence is due to detention.
Psych Hospital Checkbox
Check this box if the child's absence is due to being in a psychiatric hospital.
Medical Hospital Checkbox
Check this box if the child's absence is due to being in a medical hospital.
Alcohol & Drug Treatment Checkbox
Check this box if the child's absence is due to receiving alcohol and drug treatment.
Check Box18 CheckBox