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Children's Bureau
Child and Family Services Reviews
Case Elimination Worksheet

The following chart should be used by States to inform the Children’s Bureau Regional Office of cases that have been eliminated from the Child and Family Services Review onsite review sample. Please complete all fields for each case eliminated and submit the document to the Regional Office once the sample has been finalized. Guidelines regarding elimination of case from the sample are included in the document Criteria for Eliminating Cases From Sample Lists.

State:

County:

County FIPS Code:

[Site Name] In-Home Services Cases

No.	Case ID	Case Name	Type of Case (e.g., JJ, CMH)	Case Worker ID	Reason for Elimination
1	blank cell	blank cell	blank cell	blank cell	blank cell
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25	blank cell	blank cell	blank cell	blank cell	blank cell

 

[Site Name] Foster Care Cases

No.	Case ID	Case Name	Sample Category	Case Worker ID	Reason for Elimination
1	blank cell	blank cell	blank cell	blank cell	blank cell
2	blank cell	blank cell	blank cell	blank cell	blank cell
3	blank cell	blank cell	blank cell	blank cell	blank cell
4	blank cell	blank cell	blank cell	blank cell	blank cell
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11	blank cell	blank cell	blank cell	blank cell	blank cell
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13	blank cell	blank cell	blank cell	blank cell	blank cell
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21	blank cell	blank cell	blank cell	blank cell	blank cell
22	blank cell	blank cell	blank cell	blank cell	blank cell
23	blank cell	blank cell	blank cell	blank cell	blank cell
24	blank cell	blank cell	blank cell	blank cell	blank cell
25	blank cell	blank cell	blank cell	blank cell	blank cell

 

This chart is also available in other formats (including guidelines): (PDF - 105 KB) (Excel - 112 KB)