016.15.11. FAMILY SERVICES FORMS MANUAL
AR ADC 016.15.11Arkansas Administrative Code
Ark. Admin. Code 016.15.11
016.15.11. FAMILY SERVICES FORMS MANUAL
TABLE OF CONTENTS
Each form can be accessed based on the letter in parentheses following the form number. “R” means that the form is a report generated by CHRIS; “T” means that the form is a template contained in Microsoft WORD (A hard copy of the template is also contained in the Forms Manual); and “G” means that the form can be accessed via DHS GOLD. An asterisk besides the form number indicates that the form can be ordered from the Supply Catalog. No letter following the form number means that the form is a hard copy located in the Forms Manual to be copied as needed.
Form Number | Name of Document | Revision Date |
Missing Receipt for P-Card Transaction Form | 2/15/2011 | |
APS-0001 | Authorization for Adult Maltreatment Central Registry | 5/29/2009 |
CCRT | Child Care Referral (Protective Services/Foster Care/Supportive Services) | 5/21/2008 |
Cell Phone Cancellation of Service Instructions | Cell Phone Cancellation of Service Instructions | 6/30/2011 |
Cell Phone Order Form | Cell Phone Order or Replacement Form | 6/30/2011 |
Cell Phone Ordering Instructions | Cell Phone Ordering or Replacement Instructions) | 6/30/2011 |
CFS-0001 | Referral for Transitional Services & Support | 6/1/2011 |
CFS-0002 | Life Plan & Agreement for Youth in Transition | 6/1/2011 |
CFS-0003 | Checklist for Youth Exiting Care | 6/1/2011 |
CFS-0004 | Request for After Care Support | 6/1/2011 |
CFS-0025 | Transitional Youth Services Budget | 1/1/2011 |
CFS-0201-A | Notice of Child Maltreatment Allegation to Law Enforcement and Prosecuting Attorney | 10/1/2010 |
CFS-0202-A | Notice of Child Maltreatment Allegation to Licensing/Registering Authority | 9/19/2011 |
CFS-0204-A | Notice of Child Maltreatment Allegation to Legal Parent(s), Legal Guardian(s) and Current Foster Parent(s) of Alleged Offender in Foster Care | 10/1/2010 |
CFS-0204-A Spanish | Notice of Child Maltreatment Allegation to Legal Parent(s), Legal Guardian(s) and Current Foster Parent(s) of Alleged Offender in Foster Care (Spanish) | 6/25/2010 |
CFS-0205-A | Notice of Child Maltreatment Allegation to Legal Parent(s), Legal Guardian(s), and Current Foster Parent(s) of Alleged Victim(s) in Foster Care | 10/1/2010 |
CFS-0205-A Spanish | Notice of Child Maltreatment Allegation to Legal Parent(s), Legal Guardian(s), and Current Foster Parent(s) of Alleged Victim(s) in Foster Care (Spanish) | 10/1/2010 |
CFS-0206-A | Notice of Child Maltreatment Allegation to Attorney Ad Litem, CASA, and Counsel in Dependency Neglect or FINS Case of Alleged Victim(s) | 10/1/2010 |
CFS-0208-A | Notice of Child Maltreatment Allegation to Attorney Ad Litem and CASA of Alleged Offender | 10/1/2010 |
CFS-0209-A | Notice of Child Maltreatment Allegation to AAL or CASA of Child in Foster Home Where Maltreatment Is Reported or Where an Alleged Juvenile Offender or Underaged Juvenile Offender is Placed | 9/19/2011 |
CFS-0210-A | Notice of Child Maltreatment Allegation to Coordinator of Multidisciplinary Team for Alleged Victim or Offender; and Counsel in Dependency Neglect or FINS Case for Alleged Offender | 9/19/2011 |
CFS-0212-A | Notice of Child Maltreatment Allegation to Alleged Offender | 9/19/2011 |
CFS-0212-A Spanish | Notice of Child Maltreatment Allegation to Alleged Offender (Spanish) | 8/1/2009 |
CFS-0213-A | School District Prohibition from Notifying a Parent, Guardian, or Custodian of a Child Maltreatment Investigation | 9/19/2011 |
CFS-0213-A Spanish | School District Prohibition from Notifying a Parent, Guardian, or Custodian of a Child Maltreatment Investigation | 9/19/2011 |
CFS-0214-R | Notice of Child Maltreatment Allegation to Employer, Entity in Charge of Paid or Volunteer Activity, or Licensing or Registering Authority | 10/1/2010 |
CFS-0214-R1 | Follow-up Notice to Employer or Volunteer Coordinator, or Licensing or Registering Authority Regarding Child Maltreatment Allegation | 10/1/2010 |
CFS-0215-R | Risk Determination of Child(ren) under Care of Alleged Offender | 10/1/2010 |
CFS-0221-T | Child Maltreatment True Investigative Determination Notice to Law Enforcement and Prosecuting Attorney | 10/1/2010 |
CFS-0222-T | Child Maltreatment True Investigative Determination Notice to Facility Director | 2/20/2012 |
CFS-0223-T1 | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender (Under 13 Years old) | 2/20/2012 |
CFS-0223-T1_Spanish | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender (Under 13 Years old) | 2/20/2012 |
CFS-0223-T2 | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender 13-15 Years of Age | 2/20/2012 |
CFS-0223-T2_Spanish | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender 13-15 Years of Age | 2/20/2012 |
CFS-0223-T3 | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender 16-17 Years of Age | 2/20/2012 |
CFS-0223-T3_Spanish | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender 16-17 Years of Age | 2/20/2012 |
CFS-0223-T4 | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender Currently 18 or Older | 2/20/2012 |
CFS-0223-T4_Spanish | Child Maltreatment True Investigative Determination Notice to Underaged Juvenile Offender Currently 18 or Older | 2/20/2012 |
CFS-0224-T1 | Child Maltreatment True Investigative Determination Notice to Legal Parents and Guardians of Underaged Juvenile Offender (under 13 years old) | 2/20/2012 |
CFS-0224-T1_Spanish | Child Maltreatment True Investigative Determination Notice to Legal Parents and Guardians of Underaged Juvenile Offender (under 13 years old) | 2/20/2012 |
CFS-0224-T2 | Child Maltreatment True Investigative Determination Notice to Legal Parents and Guardians of Alleged Juvenile Offender 13-15 Years of Age | 2/20/2012 |
CFS-0224-T2_Spanish | Child Maltreatment True Investigative Determination Notice to Legal Parents and Guardians of Alleged Juvenile Offender 13-15 Years of Age | 2/20/2012 |
CFS-0224-T3 | Child Maltreatment True Investigative Determination Notice to Legal Parent(s) Guardian(s) of Alleged Juvenile Offender 16-17 Years of Age | 2/20/2012 |
CFS-0224-T3_Spanish | Child Maltreatment True Investigative Determination Notice to Legal Parent(s) Guardian(s) of Alleged Juvenile Offender 16-17 Years of Age | 2/20/2012 |
CFS-0224-T4 | Child Maltreatment True Investigative Determination Notice to Current Foster Parents of the Alleged Offender in Foster Care | 2/20/2012 |
CFS-0224-T4_Spanish | Child Maltreatment True Investigative Determination Notice to Current Foster Parents of the Alleged Offender in Foster Care | 2/20/2012 |
CFS-0225-T1 | Child Maltreatment True Investigative Determination Notice to Victim, Legal Parent(s), and Legal Guardian(s) of the Alleged Victim | 10/1/2010 |
CFS-0225-T1 | Child Maltreatment True Investigative Determination Notice to Victim, Legal Parent(s), and Legal Guardian(s) of the Alleged Victim (Spanish) | 10/1/2010 |
CFS-0225-T2 | Child Maltreatment True Investigative Determination Notice to Current Foster Parents of Alleged Victim in Foster Care | 10/1/2010 |
CFS-0225-T2 | Child Maltreatment True Investigative Determination Notice to Current Foster Parents of Alleged Victim in Foster Care | 10/1/2010 |
CFS-0226-T1 | Child Maltreatment True Investigative Determination Notice to Circuit Judge, Attorney Ad Litem, CASA, and Counsel in Dependency Neglect or FINS Case of Alleged Victim | 9/19/2011 |
CFS-0228-T | Child Maltreatment True Investigative Determination Notice to Attorney Ad Litem and CASA of Alleged Offender | 9/19/2011 |
CFS-0229-T | Child Maltreatment True Investigative Determination Notice to Attorney Ad Litem and CASA for Child in Foster Home Where Maltreatment Is Reported | 9/19/2011 |
CFS-0230-T | Child Maltreatment True Investigative Determination Notice to DHS Division Director; Coordinator of Multidisciplinary team for Alleged Victim or Offender; and Circuit Judge and Counsel in Dependency Neglect or FINS Case for Alleged Offender | 9/19/2011 |
CFS-0231-T | Child Maltreatment True Investigative Determination Notice to School Where Victim Is Enrolled | 10/1/2010 |
CFS-0232-T EH | Expedited Hearing Request | 8/1/2009 |
CFS-0232-T PH | Request for Preliminary Administrative Hearing | 10/1/2010 |
CFS-0232-T1 | Child Maltreatment True Investigative Determination Notice to Alleged Adult Offender | 10/1/2010 |
CFS-0232-T1 A | Witness Statement of Notice of Investigative Determination | 10/1/2010 |
CFS-0232-T1 A Spanish | Witness Statement of Notice of Investigative Determination (Spanish) | 8/1/2009 |
CFS-0232-T1 Spanish | Child Maltreatment True Investigative Determination Notice to Alleged Offender (Spanish) | 8/1/2009 |
CFS-0232-T2 | True But Exempt Child Maltreatment Investigative Determination Notice to Offender | 10/1/2010 |
CFS-0232-T2 Spanish | True But Exempt Child Maltreatment Investigative Determination Notice to Offender (Spanish) | 8/1/2009 |
CFS-0233-T | Child Maltreatment Expedited Hearing Notice to Alleged Offender | 10/1/2010 |
CFS-0233-T Spanish | Child Maltreatment Expedited Hearing Notice to Alleged Offender (Spanish) | 8/1/2009 |
CFS-0234-T | Child Maltreatment True Investigative Determination Notice to Licensing or Registering Authority and Employer or Volunteer Coordinator | 9/19/2011 |
CFS-0240-U1 | Unsubstantiated Child Maltreatment Investigative Determination to Alleged Underaged Juvenile Offender (under 13 Years Old) | 2/20/2012 |
CFS-0240-U1_Spanish | Unsubstantiated Child Maltreatment Investigative Determination to Alleged Underaged Juvenile Offender (under 13 Years old) | 2/20/2012 |
CFS-0240-U2 | Unsubstantiated Child Maltreatment Investigative Determination to Alleged Juvenile Offender (13-17 Years of Age) | 2/20/2012 |
CFS-0240-U2_Spanish | Unsubstantiated Child Maltreatment Investigative Determination to Alleged Juvenile Offender (13-17 Years of Age) | 2/15/2012 |
CFS-0241-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Law Enforcement and Prosecuting Attorney | 10/1/2010 |
CFS-0242-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Licensing or Registering Authority | 9/19/2011 |
CFS-0243-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Facility Director | 9/19/2011 |
CFS-0244-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Legal Parents and Legal Guardians of Alleged Offender | 9/19/2011 |
CFS-0245-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Legal Parent(s), Legal Guardians, and Current Foster Parents of the Alleged Victim | 10/1/2010 |
CFS-0245-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Legal Parent(s), Legal Guardians, and Current Foster Parents of the Alleged Victim (Spanish) | 10/1/2010 |
CFS-0245-U1 | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Alleged Victim | 10/1/2010 |
CFS-0245-U1 | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Alleged Victim (Spanish) | 10/1/2010 |
CFS-0246-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Circuit Judge, Attorney Ad Litem, CASA, and Counsel in Dependency Neglect or FINS Case of Alleged Victim | 9/19/2011 |
CFS-0248-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Attorney Ad Litem and CASA for Alleged Offender | 9/19/2011 |
CFS-0249-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Attorney Ad Litem and CASA of Child in Foster Home Where Maltreatment Is Reported | 9/19/2011 |
CFS-0250-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to DHS Division Director; Coordinator of Multidisciplinary Team for Alleged Victim or Offender; and Circuit Judge or Counsel in Dependency Neglect or FINS Case for Alleged Offender | 9/19/2011 |
CFS-0252-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Alleged Offender | 10/1/2010 |
CFS-0252-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Alleged Offender (Spanish) | 10/1/2010 |
CFS-0254-U | Notice of Unsubstantiated Child Maltreatment Investigative Determination to Alleged Offender's Employer or Entity in Charge of Alleged Offender's Paid or Volunteer Activity; or Licensing or Registering Authority | 10/1/2010 |
CFS-0261-O | Notice of Overturned True Child Maltreatment Investigative Determination to Law Enforcement and Prosecuting Attorney | 10/1/2010 |
CFS-0263-O | Notice of Overturned True Child Maltreatment Investigative Determination to Facility Director | 10/1/2010 |
CFS-0264-O | Notice of Overturned True Child Maltreatment Investigative Determination to Legal Parent(s) and Legal Guardian(s) of the Alleged Offender | 10/1/2010 |
CFS-0264-O | Notice of Overturned True Child Maltreatment Investigative Determination to Legal Parent(s) and Legal Guardian(s) of the Alleged Offender (Spanish) | 10/1/2010 |
CFS-0265-O-1 | Notice of Overturned True Child Maltreatment Investigative Determination to Victim and Legal Parent(s) and Legal Guardian(s) of Alleged Victim | 10/1/2010 |
CFS-0265-O-1 | Notice of Overturned True Child Maltreatment Investigative Determination to Victim and Legal Parent(s) and Legal Guardian(s) of Alleged Victim (Spanish) | 10/1/2010 |
CFS-0265-O-2 | Notice of Overturned True Child Maltreatment Investigative Determination to Current Foster Parent(s) of the Alleged Victim | 10/1/2010 |
CFS-0266-O | Notice of Overturned True Child Maltreatment Investigative Determination to Circuit Judge, Attorney Ad Litem, CASA, and Counsel in Dependency Neglect or FINS Case of Alleged Victim | 10/1/2010 |
CFS-0268-O | Notice of Overturned True Child Maltreatment Investigative Determination to Attorney Ad Litem and CASA of Alleged Offender | 10/1/2010 |
CFS-0269-O | Notice of Overturned True Child Maltreatment Investigative Determination to Attorney Ad Litem and CASA of Child in Foster Home Where Maltreatment Is Reported | 10/1/2010 |
CFS-0270-O | Notice of Overturned True Child Maltreatment Investigative Determination to DHS Division Director; Coordinator of Multidisciplinary Team for Alleged Victim and Offender; and Circuit Judge and Counsel in Dependency Neglect or FINS Case of Alleged Offender | 10/1/2010 |
CFS-0272-O | Notice of Overturned True Child Maltreatment Investigative Determination to Alleged Offender | 10/1/2010 |
CFS-0272-O | Notice of Overturned True Child Maltreatment Investigative Determination to Alleged Offender (Spanish) | 10/1/2010 |
CFS-0274-O | Notice of Overturned True Child Maltreatment Investigative Determination to Licensing or Registering Authority and Employer or Entity in Charge of Paid or Volunteer Activity | 10/1/2010 |
CFS-0275-O | Notice of Overturned True Child Maltreatment Investigative Determination to Child Safety Center Involved in Investigation of Maltreatment | 10/1/2010 |
CFS-0281-N | Notice of Name Placement on Central Registry to Law Enforcement and Prosecuting Attorney | 10/1/2010 |
CFS-0283-N | Notice of Name Placement on Central Registry to Facility Director | 10/1/2010 |
CFS-0284-N | Notice of Name Placement on Central Registry to Legal Parent(s) and Legal Guardian(s) of the Juvenile Offender (13 to 17 Years of Age) | 9/19/2011 |
CFS-0284-N Spanish | Notice of Name Placement on Central Registry to Legal Parent(s) and Legal Guardian(s) of the Juvenile Offender (10 to 17 Years of Age) (Spanish) | 9/19/2011 |
CFS-0285-N | Notice of Name Placement on Central Registry to Victim, Legal Parent(s), Legal Guardian(s), and Current Foster Parent(s) of Victim | 10/1/2010 |
CFS-0285-N | Notice of Name Placement on Central Registry to Victim, Legal Parent(s), Legal Guardian(s), and Current Foster Parent(s) of Victim | 10/1/2010 |
CFS-0285-N Spanish | Notice of Name Placement on Central Registry to Victim, Legal Parent(s), Legal Guardian(s), and Current Foster Parent(s) of Victim (Spanish) | 8/1/2009 |
CFS-0286-N | Notice of Name Placement on Central Registry to Circuit Judge, Attorney Ad Litem, CASA, and Counsel in Dependency Neglect or FINS Case of Victim | 10/1/2010 |
CFS-0288-N | Notice of Name Placement on Central Registry to Attorney Ad Litem and CASA of Offender | 10/1/2010 |
CFS-0289-N | Notice of Name Placement on Central Registry to Attorney Ad Litem and CASA of Child in Foster Home Where Maltreatment Is Reported | 10/1/2010 |
CFS-0290-N | Notice of Name Placement on Central Registry to DHS Division Director; Coordinator of Multidisciplinary Team for Offender and Victim; and Circuit Judge and Counsel in Dependency Neglect or FINS Case of Offender | 10/1/2010 |
CFS-0291-N1 | Notice of Name Placement on Central Registry to School Where Victim Is Enrolled | 10/1/2010 |
CFS-0291-N2 | Notice of Name Placement on Central Registry to School Where Offender Is Enrolled | 10/1/2010 |
CFS-0292-N | Notice of Name Placement on Central Registry to Offender | 10/1/2010 |
CFS-0292-N | Notice of Name Placement on Central Registry to Offender (Spanish) | 10/1/2010 |
CFS-0293-N | Notice of Name Placement on Central Registry to Mandated Reporter | 10/1/2010 |
CFS-0293-N | Notice of Name Placement on Central Registry to Mandated Reporter (Spanish) | 10/1/2010 |
CFS-0294-N | Notice of Name Placement on Central Registry to Licensing or Registering Authority, Employer, or Entity in Charge of a Paid or Volunteer Activity | 10/29/2010 |
CFS-0295-N | Notice of Name Placement on Central Registry to Child Safety Center Involved in Investigation of Maltreatment | 10/29/2010 |
CFS-0296-N | Notice of Name Placement on Central Registry to Employer of Offender in a Designated Position with an Arkansas State Agency | 10/29/2010 |
CFS-0300 | Notification of Changes in Out-of-Home Placement | 11/1/2005 |
CFS-0300 Spanish | Notification of Changes in Out-of-Home Placement (Spanish) | 11/1/2005 |
CFS-0300A | Attorney-Ad-Litem, Court Appointed Special Advocate and Child Notification of Changes in Out-of-Home Placement | 11/1/2005 |
CFS-0304 | Justification for Special Board Rate Form | 3/1/2005 |
CFS-0313 | Office of Chief Counsel Review of Administrative Hearing Investigative Determination | 2/1/2008 |
CFS-0316 | Request for Child Maltreatment Central Registry Check | 8/22/2011 |
CFS-0317 | Off-Site Worker's Safety Log | 10/29/2009 |
CFS-0320 | Administrative Hearing Statement | 4/13/2010 |
CFS-0321 | Referral for Investigation | 6/1/2009 |
CFS-0322 | Homemaker Referral | 6/1/1980 |
CFS-0323 | Protective Custody/Parental Notification | 6/1/2009 |
CFS-0323-A | Notice to Adult Relatives by Blood, Adoption or Marriage that a Child Has Been Taken into DCFS Custody | 11/1/2011 |
CFS-0323 A Spanish | Notice to Adult Relatives by Blood, Adoption or Marriage that a Child Has Been Taken into DCFS Custody (Spanish) | 11/1/2011 |
CFS-0323 B | Notice to Fictive Kin that a Child Has Been Taken into DCFS Custody | 11/1/2011 |
CFS-0323 B Spanish | Notice to Fictive Kin that a Child Has Been Taken into DCFS Custody (Spanish) | 11/1/2011 |
CFS-0324 | Checklist of Homemaker's Activities | 6/1/1980 |
CFS-0325 | Notification of Complaint Other Than Child Maltreatment | 9/1/1991 |
CFS-0326 | Outcome of Complaint Investigation (Other Than Child Maltreatment) | 9/1/2000 |
CFS-0327 | Notification of Name Removal from the Central Registry | 6/1/2009 |
CFS-0327 Spanish | Notification of Name Removal from the Central Registry (Spanish) | 6/1/2009 |
CFS-0327-A | Physical Documentation - Body Diagram | 10/20/2010 |
CFS-0328A | Request for Name Removal From the Central Registry | 7/1/2009 |
CFS-0328B | Request for Name Removal from the Central Registry by Juvenile Offender | 8/15/2009 |
CFS-0329 | Child Death Notification | 3/1/2000 |
CFS-0332 | Income Assistance Request Log | 6/1/1993 |
CFS-0333 | Client Information Sheet for Cash Assistance and Foster Care Incidentals | 9/1/2003 |
CFS-0334 | FOSTER CARE SERVICES - AUTHORIZATION FOR BILLING | 8/1/2010 |
CFS-0336 | Expiration of Protective Custody/Parental Notification | 5/1/1997 |
CFS-0336 Spanish | Expiration of Protective Custody/Parental Notification (Spanish) | 5/1/1997 |
CFS-0340 | Permanency Roundtable Referral Form | 2/20/2012 |
CFS-0341 | Certification of Absence of Criminal Record | 1/1/2011 |
CFS-0342 | State Police Criminal Record Check | 8/22/2011 |
CFS-0343 | Notification of Court Appearance | 11/1/2011 |
CFS-0343 | Notification of Court Appearance (Spanish) | 11/1/2011 |
CFS-0345 | Intensive Family Services Referral | 9/21/2010 |
CFS-0347 | Intensive Family Services Family Counselor's Time Record | 12/1/1997 |
CFS-0351 | Initial Dental Examination | 8/1/1993 |
CFS-0352 | Medical, Dental, Vision, Hearing & Psychological Episodic Form | 7/1/2010 |
CFS-0353 | Requested Medical Records Log | 4/1/1993 |
CFS-0360 | Request for Conference/Training | 7/1/1995 |
CFS-0362 | Medi-Alert to Foster Care Provider | 4/9/2007 |
CFS-0363 | Foster Parent, Adoptive Parent or Applicant Smoking Certification | 2/1/2008 |
CFS-0363 Spanish | Foster Parent, Adoptive Parent or Applicant Smoking Certification (Spanish) | 2/1/2008 |
CFS-0365 | Receipt For Medical Passport of a Foster Child and Acknowledgement of Confidential Nature of Information Contained in the Medical Passport | 8/1/1990 |
CFS-0367 | Specialized Placement Referral Form | 11/1/2010 |
CFS-0368 | Child's Health Services Plan | 9/1/2005 |
CFS-0370 | Residence Checklist for Youth | 6/1/2011 |
CFS-0376 | Authorization for Billing & Trust Account Action | 10/1/2001 |
CFS-0377 | Facility Trust Account Report | 10/1/2001 |
CFS-0379 | Close Out/Overpayment Notification | 10/1/2001 |
CFS-0380 | Trust Account Invoice | 10/1/2001 |
CFS-0381 | Training Record Log | 10/1/1993 |
CFS-0384 | Notification to Local Education Agency of Changes in Child Placement, Changes in Schools or Experiences of Traumatic Events | 8/1/2009 |
CFS-0388 | Application & Agreement to Participate in DCFS Foster Care Driver's License Program | 2/1/2008 |
CFS-0388 Spanish | Application & Agreement to Participate in DCFS Foster Care Driver's License Program (Spanish) | 2/1/2008 |
CFS-0389 | Application & Agreement to Participate in DCFS Foster Care Driving Insurance Reimbursement Program | 1/13/2010 |
CFS-0389 Spanish | Application & Agreement to Participate in DCFS Foster Care Driving Insurance Reimbursement Program (Spanish) | 12/4/2009 |
CFS-0397 | Educational Assessment | 5/1/1994 |
CFS-0404 | General Medical Report | 3/1/2008 |
CFS-0408 | Federal Parent Locator System Information | 10/20/2009 |
CFS-0409 | Foster/Adoptive Family Preference Checklist | 12/1/2009 |
CFS-0411 | Affidavit | 11/2/2009 |
CFS-0414 | Adoption Services Change of Status | 10/1/2005 |
CFS-0418 | Notice of Custody w/Power to Consent to Adoption Procedure | 5/1/2002 |
CFS-0419 | Foster Family Support System (FFSS) Information | 1/1/2011 |
CFS-0420 | Legal Risk Adoption Placement Agreement | 10/20/2009 |
CFS-0423 | Certificate of Service | 9/1/2008 |
CFS-0425 | Application for Adoption Subsidy | 9/19/2011 |
CFS-0426 | Statement of Income and Resources for Adoption Subsidy | 3/3/2010 |
CFS-0427 | Determination of Eligibility for Adoption Subsidy | 9/19/2011 |
CFS-0428-A | Adoption Assistance Agreement For State Funded Subsidy Payments | 2/20/2012 |
CFS-0428-B | Adoption Assistance Agreement For Federal IV-E Funded Assistance | 2/20/2012 |
CFS-0428-C | Adoption Assistance Agreement For Non-Recurring Adoption Expense Payment | 9/1/2003 |
CFS-0429 | Special Adoption Subsidy Determination | 11/1/2007 |
CFS-0431 | Certification of Adoption Subsidy Eligibility | 6/1/2007 |
CFS-0432 | Recommendation for Finalization of an Adoption | 8/22/2011 |
CFS-0433 | Individualized Adoption Recruitment Plan | 9/1/2003 |
CFS-0434 | Mutual Consent Voluntary Adoption Registry | 9/1/2003 |
CFS-0435-A | Subsidized Guardianship Application and Checklist | 11/1/2011 |
CFS-0435-B | Notification of Subsidized Guardianship Program Denial | 11/1/2011 |
CFS-0435-C | Subsidized Guardianship Special Subsidy Request | 11/1/2011 |
CFS-0435-D | Recommendation for Finalization of Guardianship | 4/16/2012 |
CFS-0435-F | Subsidized Guardianship Agreement | 11/1/2011 |
CFS-0435-G | Annual Subsidized Guardianship Review | 11/1/2011 |
CFS-0435-H | Notice of Modification or Termination of Subsidized Guardianship Agreement | 11/1/2011 |
CFS-0445 | Foster Home Needs Assessment | 1/1/2005 |
CFS-0446 | In Home Consultation Visit Report | 2/20/2012 |
CFS-0450 | Provisional Foster Home Referral | 6/1/2011 |
CFS-0451 | Foster Parent Re-Evaluation | 2/1/2005 |
CFS-0452 | Provisional Foster Home Verification | 8/1/2009 |
CFS-0455 | Request / Consent for Health Department Services | 6/1/2011 |
CFS-0456 | Birth Family Background Information | 3/1/1999 |
CFS-0457 | Hospital Data | 2/1/2005 |
CFS-0462 | Initial Foster Home Agreement | 8/1/2009 |
CFS-0462-A | Foster Home Agreement Addendum | 10/20/2010 |
CFS-0465 | Foster Parent Orientation Checklist | 7/1/2004 |
CFS-0465 Spanish | Foster Parent Orientation Checklist (Spanish) | 7/1/2004 |
CFS-0467 | Adoption Recruitment Agreement | 9/1/2003 |
CFS-0470 | Selection of Adoptive Family | 9/1/2003 |
CFS-0471 | Disclosure for Adoption | 2/1/2005 |
CFS-0474 | Provisional Foster Home Orientation Checklist | 10/1/2008 |
CFS-0475-A | Initial Checklist for Foster/Adoptive Home Assessment | 8/22/2011 |
CFS-0475-B | Quarterly Monitoring Checklist for Foster Home | 8/22/2011 |
CFS-0475-C | Reevaluation Checklist for Foster Home/Pre-Adoptive | 8/22/2011 |
CFS-0475-D | Transfer of a Foster Home to Another County | 8/22/2011 |
CFS-0475-E | Complaint Against Foster Family Other Than Child Maltreatment | 8/22/2011 |
CFS-0475-F | True Reports of Child Maltreatment Against Foster Family Members | 8/22/2011 |
CFS-0475-G | Checklist for Foster Home Closure | 8/22/2011 |
CFS-0476 | DCFS Training Completion Certificate | 1/1/2008 |
CFS-0480 | Alternate Compliance of Water Supply Agreement | 2/1/2005 |
CFS-0482 | Foster Home Approval Letter | 8/1/2004 |
CFS-0483 | Foster Home Re-evaluation Letter | 8/1/2004 |
CFS-0486 | SSI Screening | 11/1/2011 |
CFS-0487 | Application for Title IV-E Payments/Medicaid | 11/2/2009 |
CFS-0488 | Title IV-E Eligibility Summary | 10/1/2010 |
CFS-0489 | Foster Parent Request for Consideration to Adopt | 3/1/2008 |
CFS-0490 | Title IV-E & Medicaid Eligibility Redetermination Summary | 2/18/2011 |
CFS-0491 | Consent for Use of Funds and Resources | 11/2/2009 |
CFS-0492 | Title IV-E Medicaid Eligibility Redetermination Summary | 6/1/2011 |
CFS-0493 | Title IV-E Medicaid Redetermination | 11/1/2011 |
CFS-0494 | Notification of Adoption for Medicaid | 11/6/2009 |
CFS-0495 | Notification of Change | 10/20/2009 |
CFS-0496 | Assessment for Income Assistance | 6/1/1993 |
CFS-0509-A | Recommendation To The Child Welfare Agency Review Board | 8/1/2006 |
CFS-0509-B | Request For Alternative Compliance or Policy Waiver | 4/1/2008 |
CFS-0590 | Invitation to Family-Centered Meeting | 10/20/2009 |
CFS-0590 Spanish | Invitation to Family-Centered Meeting (Spanish) | 8/1/2009 |
CFS-0592 | Financial/Medical Plan Interstate Compact on the Placement of Children | 10/20/2009 |
CFS-0593 | DCFS Arkansas State Vehicle Safety Program | 9/1/2007 |
CFS-0594 | Meal Voucher Authorization for "FEED THE KIDS" Program | 2/23/2010 |
CFS-0595 | Meal Authorization Log for "FEED THE KIDS" Program | 11/2/2009 |
CFS-0597 | Request to Open a Medicaid Account on an ICPC Case | 11/1/2006 |
CFS-1136 | DCFS Employee Orientation Checklist Addendum | 9/1/2008 |
CFS-4330 | Child Welfare Student Stipend Agreement | 4/13/2010 |
CFS-4331 | Educational Leave Contract - (Full-time/Part-time MSW Student) | 11/2/2009 |
CFS-4332 | Child Welfare Student Stipend Application | 10/1/2001 |
CFS-6010 Addendum - A | Visitation Plan for New Case Plan | 8/1/2006 |
CFS-6010 Addendum - B | Independent Living Skills | 8/1/2006 |
CFS-6013 | Application for Emergency Services | 7/1/2006 |
CFS-6024 | Permanency Planning Court Report | 6/1/2004 |
CFS-6091 | ICPC Parent / Relative Home Study Check List | 8/1/2009 |
CFS-6092 | ICPC Home Study Request Check List | 4/7/2010 |
CFS-6092-C | ICPC Cover Letter | 8/18/2010 |
CFS-6092-S | ICPC Social Summary | 4/7/2010 |
CFS-6093 | ICPC Foster Care Home Study Check List | 8/1/2009 |
CFS-6094 | ICPC Adoptive Home Study Check List | 8/1/2009 |
DHS-0081 | Consent for Release of Information | 5/1/1994 |
DHS-0359 | DHS Systems Security Access Request | 8/25/2009 |
DHS-4000 | Authorization to Disclose Health Information | 11/1/2005 |
Foster Parent ITNA | The Learning Needs Assessment Tool | 1/3/2011 |
Foster Parent ITNA Tally Sheet | The Learning Needs Assessment Tally Sheet | 1/3/2011 |
ICPC-100A | Interstate Compact Placement Request | 10/20/2009 |
ICPC-100B | Interstate Compact Report on Child's Placement Status | 10/20/2009 |
ICPC-101 | ICPC Sending State Priority Home Study Request | 10/20/2009 |
ICPC-30 | ICPC Supervision Report-30 day | 7/7/2010 |
ICPC-90 | ICPC Supervision Report-90 day | 7/7/2010 |
NYTD Survey | NYTD Survey | 10/1/2010 |
OCC-0410 | Consent to Termination of Parental Rights | 3/30/2009 |
OCC-0410 Spanish | Consent to Termination of Parental Rights (Spanish) | 3/1/2009 |
Request for OST CHRIS Report | Request for OST CHRIS Report | 10/20/2009 |
Request for Service / Encumbrance (Non-Placement Services Only) | Request for Service / Encumbrance (Non-Placement Services Only) | 10/20/2009 |
SS-5-FS | Application for a Social Security Card | 8/1/2009 |
VR-0007 | Birth Certificate Application | 1/1/2009 |
VSP | Arkansas State Vehicle Safety Program | 7/1/2010 |
VSP-1 | Authorization to Operate State Vehicles and Private Vehicles on State Business | 9/28/2010 |
VSP-2 | Authorization to Obtain Traffic Violation Record | 9/28/2010 |
Current with amendments received through February 15, 2024. Some sections may be more current, see credit for details.
Ark. Admin. Code 016.15.11, AR ADC 016.15.11
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