ACYF-CB-IM-02-05 Appendix G

APPENDIX G

SAMPLE CASE FILE REVIEW FORM

This form will be generated automatically by ACF with all information submitted for the record by the participating State. This is an example of only one page. A report is generated for both Adoption and Foster Care.

Foster Care Case Review Report Report Period: October 1, 2004 - March 31, 2005 State: Bliss AFCARS Record Number: XN5000001235 Sate Client Identifier: Child's #
AFCARS Element	Data from AFCARS	Data from Paper File	Data Do Not Match (X)
#3 Local FIPS Code	Clinton	blank cell	blank cell
#5 Date of Most Recent Periodic Review	July 08, 2002	blank cell	blank cell
#6 Child Birth Date	August 22, 1988	blank cell	blank cell
#7 Child Sex	Male	blank cell	blank cell
#8 Child Race	blank cell	blank cell	blank cell
a. American Indian/Alaska Native	No	blank cell	blank cell
b. Asian	No	blank cell	blank cell
c. Black/African American	No	blank cell	blank cell
d. Hawaiian/Pacific Islander	No	blank cell	blank cell
e. White	Yes	blank cell	blank cell
f. Unable to determine	No	blank cell	blank cell
#9 Child Hispanic Origin	Yes	blank cell	blank cell
#10 Has Child Been Diagnosed with Disability?	No	blank cell	blank cell
#11 Mental Retardation	Condition does not apply	blank cell	blank cell
#12 Visually/Hearing Impaired	Condition does not apply	blank cell	blank cell
#13 Physically Disabled	Condition does not apply	blank cell	blank cell
#14 Emotionally Disturbed	Condition does not apply	blank cell	blank cell
#15 Other Diagnosed Condition	Condition does not apply	blank cell	blank cell
#16 Has Child Ever Been Adopted	No	blank cell	blank cell
#17 Age at Adoption	Not Applicable	blank cell	blank cell
#18 Date of First Removal from Home	April 10, 2000	blank cell	blank cell
#19 Total Number of Removals from Home	01	blank cell	blank cell
#20 Date of Discharge from Last Episode	-	blank cell	blank cell
#21 Date of Latest Removal	April 10, 2000	blank cell	blank cell
#23 Date of Placement in Current Setting	October 24, 2002	blank cell	blank cell
#24 Number of Previous Placement Settings in Episode	07	blank cell	blank cell
#25 Manner of Removal from Home	Court Ordered	blank cell	blank cell
#26 Condition Associated with Removal - Physical Abuse	Condition Applies	blank cell	blank cell
#27 Sexual Abuse	Condition Applies	blank cell	blank cell
#28 Neglect	Condition Applies	blank cell	blank cell
#29 Parent Alcohol Abuse	Condition Applies	blank cell	blank cell
#30 Parent Drug Abuse	Condition Applies	blank cell	blank cell
#31 Child Alcohol Abuse	Condition Does not Apply	blank cell	blank cell
#32 Child Drug Abuse	Condition Does not Apply	blank cell	blank cell
#33 Child Disability	Condition Does not Apply	blank cell	blank cell
#34 Child's Behavior Problem	Condition Applies	blank cell	blank cell
#25 Death of Parent	Condition Does not Apply	blank cell	blank cell
#36 Incarceration of Parent	Condition Applies	blank cell	blank cell
#37 Caretaker Inability to Cope Due to Illness or Other Reasons	Condition Applies	blank cell	blank cell
#38 Abandonment	Condition Does not Apply	blank cell	blank cell
#39 Relinquishment	Condition Does not Apply	blank cell	blank cell
#40 Inadequate Housing	Condition Applies	blank cell	blank cell
#41 Current Placement Setting [These are not listed on the form] 1 = Pre-Adoptive Home 2 = Foster Family Home-Relative 3 = Foster Family Home-Non-Relative 4 = Group Home 5 = Institution 6 = Supervised Independent Living 7 = Runaway 8 = Trial Home Visit	Foster Family Home (non-relative)	blank cell	blank cell
#42 Is Current Placement Out-of-State?	No	blank cell	blank cell
#43 Most recent case plan goal [These are not listed on the form.] 1 = Reunify With Parent(S) Or Principal Caretaker(S) 2 = Live With Relative(S) 3 = Adoption 4 = Long Term Foster Care 5 = Emancipation 6 = Guardianship 7 = Case Plan Goal Not Yet Established	Adoption	blank cell	blank cell
#44 Caretaker Family Structure [These are not listed on the form.] 1 = Married Couple 2 = Unmarried Couple 3 = Single Female 4 = Single Male 5 = Unable to Determine	Single Female	blank cell	blank cell
#45 1 st Primary Caretaker's Birth Year	1971	blank cell	blank cell
#46 2 nd Primary Caretaker's Birth Year (if applicable)	-	blank cell	blank cell
#47 Mother's Date of TPR	April 23, 2002	blank cell	blank cell
#48 Legal or Putative Father' TPR	January 30, 2002	blank cell	blank cell
#49 Foster Family Structure	Single Female	blank cell	blank cell
#50 1 st Foster Caretaker's Birth Year	1972	blank cell	blank cell
#51 2 nd Foster Caretaker's Birth Year	-	blank cell	blank cell
#52 1 st Foster Caretaker's Race	blank cell	blank cell	blank cell
a. American Indian/Alaska Native	No	blank cell	blank cell
b. Asian	No	blank cell	blank cell
c. Black/African American	No	blank cell	blank cell
d. Hawaiian/Pacific Islander	No	blank cell	blank cell
e. White	Yes	blank cell	blank cell
f. Unable to determine	No	blank cell	blank cell
#53 1 st Foster Caretaker's Hispanic or Latino Origin	Yes	blank cell	blank cell
#54 2 nd Foster Caretaker's Race (if applicable)	blank cell	blank cell	blank cell
a. American Indian/Alaska Native	-	blank cell	blank cell
b. Asian	-	blank cell	blank cell
c. Black/African American	-	blank cell	blank cell
d. Hawaiian/Pacific Islander	-	blank cell	blank cell
e. White	-	blank cell	blank cell
f. Unable to determine	-	blank cell	blank cell
#55 2 nd Foster Caretaker's Hispanic Origin	-	blank cell	blank cell
#56 Date of Discharge from foster care	-	blank cell	blank cell
#58 Reason for Discharge [These are not listed on the form] 1 = Reunification with Parent(s) or Primary Caretaker(s) 2 = Living with Other Relative(s) 3 = Adoption 4 = Emancipation 5 = Guardianship 6 = Transfer to Another Agency 7 = Runaway 8 = Death of Child	Not Applicable	blank cell	blank cell
#59 Title IV-E (Foster Care)	Condition Applies	blank cell	blank cell
#60 Title IVE (Adoption Subsidy)	Condition Does Not Apply	blank cell	blank cell
#61 Title IVA (Aid to Families with Dependent Children)	Condition Does Not Apply	blank cell	blank cell
#63 Title XIX (Medicaid)	Condition Applies	blank cell	blank cell
#64 SSI or other Social Security Act Benefits	Condition Applies	blank cell	blank cell
#65 None of the Above	Condition Does Not Apply	blank cell	blank cell
#66 Amount of monthly foster care payment (regardless of source)	0435	blank cell	blank cell

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Attachments:

ACYF-CB-IM-02-05

State Guide to an AFCARS Assessment Review HTML or PDF(332 KB)

APPENDIX G SAMPLE CASE FILE REVIEW FORM

APPENDIX G

SAMPLE CASE FILE REVIEW FORM