Norman Class Member Certification Form Instructions
This form contains 28 fields organized into 11 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Child's Name | ||
| Child's Last Name | Text |
Enter the child's last name.
|
| Child's First Name | Text |
Enter the child's first name.
|
| No (Q2 Service Plan) | Checkbox |
The user should check this box if the Service Plan does not reflect that the living circumstances are a barrier to the child(ren) remaining at home or returning home. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Environmental Neglect | Checkbox |
The user should check this box if environmental neglect is a reason for certifying the family as a Norman Class member. Fill only if 'Check Box13' is 'Yes'.
Depends on:
Check Box13
|
| Comments | ||
| Comments | Text |
Provide any additional comments or relevant information regarding the certification.
|
| CYCIS I.D. | ||
| CYCIS I.D. | Text |
Please provide the unique CYCIS Identification number.
|
| Check Box13 | CheckBox |
Depends on:
Yes
|
| Family Name | ||
| Family Last Name | Text |
Please provide the last name of the family.
|
| Family First Name | Text |
Please provide the first name of the family.
|
| Yes | Checkbox |
Check this box if the permanency goal for the child(ren) is to remain home or return home.
|
| No | Checkbox |
Check this box if the permanency goal for the child(ren) is not to remain home or return home, indicating the family is not a class member.
|
| Fifth Child's Name | ||
| Fifth Child's Full Name | Text |
Please enter the full name of the fifth child.
|
| Fourth Child's Name | ||
| Fourth Child's Full Name | Text |
Please enter the full name of the fourth child.
|
| Not a Norman Class Member | Checkbox |
Check this box if you have reviewed the case and determined that the family's living circumstances are not a barrier to the children remaining at home or returning home, and therefore the family is NOT a Norman Class member. Fill only if 'No (Q2 Service Plan)' is 'Yes'.
Depends on:
No (Q2 Service Plan)
|
| General | ||
| Text21 | Text | |
| Text22 | Text | |
| Text23 | Text | |
| Text24 | Text | |
| Text25 | Text | |
| Region/Field | ||
| Region or Field | Text |
Please enter the region or field identifier.
|
| Inadequate Food | Checkbox |
Check this box if inadequate food is a reason the family is certified as a Norman Class member. Fill only if 'Environmental Neglect' is 'Yes'.
Depends on:
Environmental Neglect
|
| Second Child's Name | ||
| Text7 | Text | |
| Inadequate Shelter | Checkbox |
Check this box if inadequate shelter is a reason for certifying the family as a Norman Class member. Fill only if 'Environmental Neglect' is 'Yes'.
Depends on:
Environmental Neglect
|
| Inadequate Clothing | Checkbox |
Check this box if inadequate clothing is a reason for certifying the family as a Norman Class member. Fill only if 'Environmental Neglect' is 'Yes'.
Depends on:
Environmental Neglect
|
| Supervisor Information | ||
| Child Welfare Supervisor Name | Text |
Please enter the name of the Child Welfare Supervisor.
|
| Date | Date |
Please enter the date.
|
| Third Child's Name | ||
| Third Child's Full Name | Text |
Please provide the full name of the third child.
|
| Environmental Neglect | Checkbox |
Check this box if environmental neglect is a reason for certifying the family as a Norman Class member, indicating that it is a barrier to the child(ren) remaining at home or returning home. Fill only if 'Environmental Neglect' is 'Yes'.
Depends on:
Environmental Neglect
|