Placement Review Staffing Report Instructions
This form contains 90 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Appellant Information | ||
| Appellant's Name | Text |
Please provide the full legal name of the appellant.
|
| Address Line 1 | Text |
Please provide the first line of the appellant's street address.
|
| Address Line 2 | Text |
Please provide the second line of the appellant's address, which may include apartment number, city, state, and zip code.
|
| Phone Number | Text |
Please provide the appellant's phone number.
|
| Appellant's Name | ||
| Appellant's Name | Text |
Please provide the full name of the appellant. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Child Information | ||
| Child Name | Text |
Please provide the full name of the child.
|
| Child ID Number | Text |
Please provide the identification number associated with the child.
|
| Child's Strengths / Needs Present | ||
| Strength/Need 1 | Text |
Enter the first strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 2 | Text |
Enter the second strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 3 | Text |
Enter the third strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 4 | Text |
Enter the fourth strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 5 | Text |
Enter the fifth strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 6 | Text |
Enter the sixth strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 7 | Text |
Enter the seventh strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 8 | Text |
Enter the eighth strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 9 | Text |
Enter the ninth strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Strength/Need 10 | Text |
Enter the tenth strength or need present for the child. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Convener | ||
| Convener Name | Text |
Provide the name of the convener for the placement review.
|
| Explanation of Disruption | ||
| Explanation of Disruption Details | Text |
Provide a summary of the information regarding the disruption, as provided by the worker, caregiver, and child.
|
| General | ||
| Text10 | Text | |
| Text11 | Text | |
| Text12 | Text | |
| Text13 | Text | |
| Text14 | Text | |
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| Text48 | Text | |
| Text49 | Text | |
| Text50 | Text | |
| Text51 | Text | |
| Text52 | Text | |
| Text53 | Text | |
| Agree for item 1 | Checkbox |
Check this box if you agree with the first listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 1 | Checkbox |
Check this box if you disagree with the first listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 2 | Checkbox |
Check this box if you agree with the second listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 2 | Checkbox |
Check this box if you disagree with the second listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 3 | Checkbox |
Check this box if you agree with the third listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 3 | Checkbox |
Check this box if you disagree with the third listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 4 | Checkbox |
Check this box if you agree with the fourth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 4 | Checkbox |
Check this box if you disagree with the fourth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 5 | Checkbox |
Check this box if you agree with the fifth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 5 | Checkbox |
Check this box if you disagree with the fifth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 6 | Checkbox |
Check this box if you agree with the sixth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 6 | Checkbox |
Check this box if you disagree with the sixth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 7 | Checkbox |
Check this box if you agree with the seventh listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 7 | Checkbox |
Check this box if you disagree with the seventh listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 8 | Checkbox |
Check this box if you agree with the eighth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 8 | Checkbox |
Check this box if you disagree with the eighth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 9 | Checkbox |
Check this box if you agree with the ninth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 9 | Checkbox |
Check this box if you disagree with the ninth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Agree for item 10 | Checkbox |
Check this box if you agree with the tenth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| Disagree for item 10 | Checkbox |
Check this box if you disagree with the tenth listed strength or need. Fill only if 'Appellant's Name' is filled
Depends on:
Appellant's Name
|
| History | ||
| Placement History Details | Text |
Provide a comprehensive review of the child's overall placement history and include details about the child's or children's adjustment to the home where the 14-day notice was issued.
|
| III. | ||
| Convener's Disruption Impression | Text |
Please provide the convener's impression or understanding of the disruption.
|
| IV. Efforts to Preserve Placement | ||
| Efforts to Preserve Placement | Text |
Enter a detailed description of all efforts made to preserve the placement.
|
| Text | ||
| Provider Number | ||
| Provider Number | Text |
Enter the identification number for the provider.
|
| Staffing Date | ||
| Staffing Date | Date |
Enter the staffing date.
|
| VI. Recommendations (Rationale for Recommendation) | ||
| Recommendation Rationale | Text |
Provide a detailed explanation of the recommendations and the rationale behind them.
|