CPS_32 Child Fatality-Serious Injury Report
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County Name __________________Date of Child Death __________ Date of Serious Injury _________________ I . IDENTIFYING INFOR!TION First Name iddle Name "ast Name DO# Ethni$ity%Se& !. Child' _____________________________________________________________________________________ #. Names of (arents' other' __________________________________________DO#' ____________In )ome*_____________________ Father' __________________________________________DO#' ____________In )ome*_____________________ C. Careta+er, if different from -arent s/ Name' ___________________________________________Relationshi-____________________________________ _______________________________________________________________________________________________ D. 0ho had le1al $ustody of $hild at time of the death%serious injury* __________________________________ E. Other -eo-le li2in1 in home at time of death%injury' If $hild has minor si3lin1s not li2in1 in the home, -lease list name, a1e and 4herea3outs in III. E, -a1e 5. another -a1e, if ne$essary. Name !1e Rel.to Child If Child, Current 0herea3outs _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _____ II. DE!T)%SERIO6S IN76RY S6!RY !. Date re-orted to DFCS' _____________ Cause of death%serious injury, +no4n or sus-e$ted, at time o re-ort' _________________________________________________________________________________________ Cir$umstan$es of fatality or serious injury 4hat ha--ened/' _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 8/ ___!3use sus-e$ted* 5/ ___Ne1le$t sus-e$ted* 9/ ___!3use and ne1le$t* :/___C!%N not sus-e$ted If 8, 5, or 9 $he$+ed 1i2e name of alle1ed maltreater' ______________________________________________ "a4 enfor$ement notified* YES___ NO___ !rrest made* YES___ NO___ !uto-sy Com-leted* YES__NO__ #. Other a1en$ies in2ol2ed 4ith assessment of fatality%serious injury' _____________________________ _______________________________________________________________________________________________ C. Si1nifi$ant medi$al information -re;e&istin1 medi$al $onditions< $urrent $ondition if injured, (a1e 8 CPS_32 Child Fatality/Serious Injury Report (Revised 09/06 DI=ISION OF F!I"Y !ND C)I"DREN SER=ICES C)I"D DE!T)%SERIO6S IN76RY RE(ORT
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Transcript of CPS_32 Child Fatality-Serious Injury Report
County Name __________________Date of Child Death __________ Date of Serious Injury ___________________
I.IDENTIFYING INFORMATIONFirst Name Middle Name Last Name
DOB Ethnicity/SexA.Child: _____________________________________________________________________________________
B. Names of Parents:
Mother: __________________________________________DOB: ____________In Home?_____________________
Father: __________________________________________DOB: ____________In Home?_____________________
C. Caretaker, if different from parent(s)
Name: ___________________________________________Relationship____________________________________
_______________________________________________________________________________________________
D. Who had legal custody of child at time of the death/serious injury?__________________________________
E. Other people living in home at time of death/injury: If child has minor siblings who are not living in the home, please list name, age and whereabouts in III. E, page 2. Add another page, if necessary.
Name
Age
Rel.to Child
If Child, Current Whereabouts
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
II.DEATH/SERIOUS INJURY SUMMARYA.Date reported to DFCS: _____________ Cause of death/serious injury, known or suspected, at time of report: _________________________________________________________________________________________
Circumstances of fatality or serious injury (what happened): _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(1) ___Abuse suspected? (2) ___Neglect suspected? (3) ___Abuse and neglect? (4)___CA/N not suspected ?
If 1, 2, or 3 checked give name of alleged maltreater: __________________________________________________
Law enforcement notified? YES___ NO___ Arrest made? YES___ NO___ Autopsy Completed? YES__NO__
B.Other agencies involved with assessment of fatality/serious injury: __________________________________
_______________________________________________________________________________________________
C.Significant medical information (pre-existing medical conditions; current condition if injured, etc.)____________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________
III.COUNTY DFCS HISTORY (Check appropriate areas)A.Open Service Cases - Current History
Comments
___ CPS opened before childs death/serious injury?
Date opened ________
___ CPS opened because of childs death/serious injury?Date opened ________
___ Prevention opened before childs death/serious injury?Date opened ________
___ PLC opened before childs death/serious injury?
Date opened ________
___ PLC opened because of childs death/serious injury?Date opened ________
___ Open Adoption case? ___ Other open Service case?Type ________________ Date ________
B.Closed Service Cases - Past History
___ Screened out CPS?
Date screened out _________
___ Closed CPS investigation?Date of referral_________ Disposition __________Date closed________
___ Closed CPS ongoing?Date opened _________Date closed_________
___ Closed Prevention?
Date opened _________Date closed_________
___ Closed PLC?
Date opened _________Date closed_________
___ Closed Adoption?
Date finalized__________
___ Other Closed Service?Type _________________________Date _________
C.Case Summary: (What are the specifics of DFCS involvement with this family? Include your knowledge of other counties involved with the family.) _______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
D. Results of risk assessment of children remaining in the home_______________________________________
_______________________________________________________________________________________________
E. Other Information (NOTE: Forward additional information within 10 days of receiving)_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Form Completed By: _____________________________Date: _____________________________
County Contact Person: ___________________________ Phone Number: ________________________________
I have taken possession of all original service case records:
County Directors/Designee Signature: ______________________________________Date: ___________________DIVISION OF FAMILY AND CHILDREN SERVICES
CHILD DEATH/SERIOUS INJURY REPORT
Page 1CPS_32 Child Fatality/Serious Injury Report (Revised 09/06)
