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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 |
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 |
5 | blank cell | blank cell | blank cell | blank cell | blank cell |
6 | blank cell | blank cell | blank cell | blank cell | blank cell |
7 | blank cell | blank cell | blank cell | blank cell | blank cell |
8 | blank cell | blank cell | blank cell | blank cell | blank cell |
9 | blank cell | blank cell | blank cell | blank cell | blank cell |
10 | blank cell | blank cell | blank cell | blank cell | blank cell |
11 | blank cell | blank cell | blank cell | blank cell | blank cell |
12 | blank cell | blank cell | blank cell | blank cell | blank cell |
13 | blank cell | blank cell | blank cell | blank cell | blank cell |
14 | blank cell | blank cell | blank cell | blank cell | blank cell |
15 | blank cell | blank cell | blank cell | blank cell | blank cell |
16 | blank cell | blank cell | blank cell | blank cell | blank cell |
17 | blank cell | blank cell | blank cell | blank cell | blank cell |
18 | blank cell | blank cell | blank cell | blank cell | blank cell |
19 | blank cell | blank cell | blank cell | blank cell | blank cell |
20 | blank cell | blank cell | blank cell | blank cell | blank cell |
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 |
[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 |
5 | blank cell | blank cell | blank cell | blank cell | blank cell |
6 | blank cell | blank cell | blank cell | blank cell | blank cell |
7 | blank cell | blank cell | blank cell | blank cell | blank cell |
8 | blank cell | blank cell | blank cell | blank cell | blank cell |
9 | blank cell | blank cell | blank cell | blank cell | blank cell |
10 | blank cell | blank cell | blank cell | blank cell | blank cell |
11 | blank cell | blank cell | blank cell | blank cell | blank cell |
12 | blank cell | blank cell | blank cell | blank cell | blank cell |
13 | blank cell | blank cell | blank cell | blank cell | blank cell |
14 | blank cell | blank cell | blank cell | blank cell | blank cell |
15 | blank cell | blank cell | blank cell | blank cell | blank cell |
16 | blank cell | blank cell | blank cell | blank cell | blank cell |
17 | blank cell | blank cell | blank cell | blank cell | blank cell |
18 | blank cell | blank cell | blank cell | blank cell | blank cell |
19 | blank cell | blank cell | blank cell | blank cell | blank cell |
20 | blank cell | blank cell | blank cell | blank cell | blank cell |
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)