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DHS-69, Foster Care/Juvenile Justice Action Summary Michigan Department of Health and Human Services (Revised 1-22) section 1 Case name  FORMTEXT   FORMTEXT      Case ID  FORMTEXT       Child name  FORMTEXT      Child person ID  FORMTEXT       Worker name  FORMTEXT      Organization  FORMTEXT      Phone number  FORMTEXT       Email  FORMTEXT      Date completed  FORMTEXT       Type of action (check as many as apply)  FORMTEXT   FORMCHECKBOX  Child fatality notification (complete section 2) Effective Date:  FORMTEXT        FORMCHECKBOX  Caseworker/organization change (complete section 3) Effective Date:  FORMTEXT        FORMCHECKBOX  Parent contact information change (complete section 4) Effective Date:  FORMTEXT        FORMCHECKBOX  Foster care transfer to adoption (complete section 5) Effective Date:  FORMTEXT        FORMCHECKBOX  Placement change (complete section 6) Effective Date:  FORMTEXT        FORMCHECKBOX  Temporary break (complete section 7) Effective Date:  FORMTEXT        FORMCHECKBOX  Foster care program closure (complete section 8) Effective Date:  FORMTEXT        FORMCHECKBOX  Juvenile justice program closure (complete section 8) Effective Date:  FORMTEXT       section 2  child fatality notification This serves as a preliminary notice that the child listed above died on  FORMTEXT   FORMTEXT      . Additional information may be requested from the  FORMTEXT       County MDHHS Office at  FORMTEXT      . Date of incident  FORMTEXT      Time of incident  FORMTEXT      Date notified of incident  FORMTEXT       Immediate notification was given to (enter N/A if not applicable)  FORMTEXT   FORMCHECKBOX  Centralized Intake on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email  FORMCHECKBOX  Local MDHHS on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email  FORMCHECKBOX  Legal parent/guardian 1 on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email  FORMCHECKBOX  Legal parent/guardian 2 on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email  FORMCHECKBOX  MCI superintendent on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email  FORMCHECKBOX  Division of Child Welfare Licensing on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email  FORMCHECKBOX  Court of jurisdiction on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email section 3  caseworker change/organization change Former caseworker s name  FORMTEXT   FORMTEXT      Telephone number  FORMTEXT       Organization  FORMTEXT      Email  FORMTEXT       New caseworker s name  FORMTEXT      Telephone number  FORMTEXT       Organization  FORMTEXT      Email  FORMTEXT       section 4  parent contact information change Parent name  FORMTEXT   FORMTEXT       Former address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip code  FORMTEXT       Former telephone  FORMTEXT      Former email  FORMTEXT       New address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip code  FORMTEXT       New telephone  FORMTEXT      New email  FORMTEXT       section 5  transfer to adoption Preparation appropriate to the child s capacity to understand has been conducted in the following way. FORMTEXT   FORMTEXT       Information related to transfer from foster care to adoption was shared with MDHHS/referring worker by:  FORMCHECKBOX  In person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email Summarize services currently being provided.  FORMTEXT       List services and needs still to be met and provisions for follow-up services, if any.  FORMTEXT       section 6  placement change Former placement name  FORMTEXT   FORMTEXT       Former placement address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip code  FORMTEXT       Former placement telephone  FORMTEXT       New placement name  FORMTEXT       New placement address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip code  FORMTEXT       Former placement telephone  FORMTEXT       This is the child s  FORMTEXT       placement since entering foster care. Describe efforts taken to maintain the child s placement and prevent the placement change.  FORMTEXT       Was consideration given to returning the child to a parent?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If the child is not returning to a parent, document the reason(s) why return to a parent would cause a substantial risk of harm to the child s life, physical health, or mental well-being.  FORMTEXT       Is the child being placed with a relative or sibling?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, document the efforts made to place with a relative or sibling and the reason why placement with a relative or sibling is not possible at this time.  FORMTEXT       Does the change in placement  FORMTEXT   FORMCHECKBOX  separate or  FORMCHECKBOX  reunite siblings?  FORMCHECKBOX  N/A: No siblings  FORMCHECKBOX  N/A: All siblings changing placement together If any siblings are separated, describe the plan for sibling visitation.  FORMTEXT       The child is being moved for the following reasons (select all that apply):  FORMTEXT   FORMCHECKBOX  The foster parent/caregiver has requested the child to be moved. FORMCHECKBOX  The court has ordered the child to be returned home. FORMCHECKBOX  The change in placement is less than 30 calendar days from the childs initial removal from his or her home. FORMCHECKBOX  The change in placement is less than 90 calendar days after the initial placement and the new placement is with a relative. FORMCHECKBOX  The supervising agency has reasonable cause to believe that the child has suffered sexual abuse or non-accidental physical injury, or there is substantial risk of harm to the childs emotional well-being or physical safety within the caregivers home. FORMCHECKBOX  The supervising agency believes it is in the child s best interest to be moved. Briefly describe the circumstances that lead to the placement change.  FORMTEXT       Placement selection criteria: rank each of the following from 1-4, with 1 being most important to the placement decision, 3 being the least important and 4 being not applicable.  FORMTEXT   FORMTEXT   The case plan which includes the goal of permanence. FORMTEXT   The physical, emotional, and safety needs of the child. FORMTEXT   Proximity to the child s family. FORMTEXT   Placement within the relative family network. FORMTEXT   Placement with siblings. FORMTEXT   The least-restrictive, most family-like setting. FORMTEXT   The continuity of relationships. FORMTEXT   The child s and child s family s religious preference. FORMTEXT   The child s expressed preferences for placement. FORMTEXT   Appropriateness of the child s current educational setting and proximity to the school the child was enrolled in at the time of removal FORMTEXT   Availability of placement resources for the purpose of timely placement. If any placement selection criteria were not met, explain why.  FORMTEXT       Does the change in placement require the child to change schools?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe the efforts to maintain the child in his/her school of origin.  FORMTEXT       Describe how the child, parent(s), previous placement, and new placement were prepared for the placement change. Explanation must be appropriate to the respective parties capacity to understand the need for the placement change.  FORMTEXT       Is the child an Indian Child as defined in MCL 712B.3(k)?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, choose active efforts to place the child in compliance with MCL 712B.23. FORMCHECKBOX  Engaging the Indian child, child's parents, tribe, extended family members, and individual Indian caregivers through the utilization of culturally appropriate services and in collaboration with the parent or child's Indian tribes and Indian social services agencies. FORMCHECKBOX  Identifying appropriate services and helping the parents to overcome barriers to compliance with those services. FORMCHECKBOX  Conducting or causing to be conducted a diligent search for extended family members for placement. FORMCHECKBOX  Requesting representatives designated by the Indian child's tribe with substantial knowledge of the prevailing social and cultural standards and child rearing practice within the tribal community to evaluate the circumstances of the Indian child's family and to assist in developing a case plan that uses the resources of the Indian tribe and Indian community, including traditional and customary support, actions, and services, to address those circumstances. FORMCHECKBOX  Completing a comprehensive assessment of the situation of the Indian child's family, including a determination of the likelihood of protecting the Indian child's health, safety, and welfare effectively in the Indian child's home. FORMCHECKBOX  Identifying, notifying, and inviting representatives of the Indian child's tribe to participate in all aspects of the Indian child custody proceeding at the earliest possible point in the proceeding and actively soliciting the tribe's advice throughout the proceeding. FORMCHECKBOX  Notifying and consulting with extended family members of the Indian child, including extended family members who were identified by the Indian child's tribe or parents, to identify and to provide family structure and support for the Indian child, to assure cultural connections, and to serve as placement resources for the Indian child. FORMCHECKBOX  Making arrangements to provide natural and family interaction in the most natural setting that can ensure the Indian child's safety, as appropriate to the goals of the Indian child's permanency plan, including, when requested by the tribe, arrangements for transportation and other assistance to enable family members to participate in that interaction. FORMCHECKBOX  Offering and employing all available family preservation strategies and requesting the involvement of the Indian child's tribe to identify those strategies and to ensure that those strategies are culturally appropriate to the Indian child's tribe. FORMCHECKBOX  Identifying community resources offering housing, financial, and transportation assistance and in-home support services, in-home intensive treatment services, community support services, and specialized services for members of the Indian child's family with special needs, and providing information about those resources to the Indian child's family, and actively assisting the Indian child's family or offering active assistance in accessing those resources. FORMCHECKBOX  Monitoring client progress and client participation in services. FORMCHECKBOX  Providing a consideration of alternative ways of addressing the needs of the Indian child's family, if services do not exist or if existing services are not available to the family. FORMCHECKBOX  Other FORMTEXT       Notification of the placement change was provided to (enter N/A if not applicable)Dates in this section should reflect date on which notification was provided using methods other than the DHS-69. Parties marked with an asterisk (*) MUST receive notification of the placement change via the DHS-69, even if notice was also provided in person, by telephone, or by email. See Section 10 for distribution list and date(s).  FORMTEXT   FORMCHECKBOX  Legal parent/guardian 1 on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  Legal parent/guardian 2 on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  *MDHHS/referring worker on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  *Child s tribe/tribal caseworker on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  MCI superintendent on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  *Lawyer-guardian ad litem on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  *Child s attorney on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  *Court of jurisdiction on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-69 FORMCHECKBOX  Previous placement on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS-30 FORMCHECKBOX  New placement on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Email  FORMCHECKBOX  DHS- 3307 section 7  temporary break Type of temporary break  FORMTEXT   FORMCHECKBOX  AWOLP  FORMCHECKBOX  Hospitalization (medical/psychiatric)  FORMCHECKBOX  Jail  FORMCHECKBOX  Detention Is the child expected to return to the previous placement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, why is the child unable to return to the previous placement, and what is the plan for placement after the temporary break.  FORMTEXT       Is there an estimated length of time for the temporary break?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, indicate the estimated length of the temporary break. If no, explain why no estimate is available.  FORMTEXT       section 8  foster care/juvenile justice case program closure Indicate program type that is closing (check as many as apply)  FORMTEXT   FORMCHECKBOX  Foster care  FORMCHECKBOX  Juvenile justice Reason(s) for case/program closure (check as many as apply)  FORMTEXT   FORMCHECKBOX  Age (emancipation/aged out) FORMCHECKBOX  AWOLP FORMCHECKBOX  Married (foster care only) FORMCHECKBOX  Military service (foster care only) FORMCHECKBOX  Moved to another state FORMCHECKBOX  OTI activity completed FORMCHECKBOX  Placed for adoption (foster care only) FORMCHECKBOX  Placed with guardian (foster care only) FORMCHECKBOX  Placed with parent (foster care only) FORMCHECKBOX  Escalated to adult system (juvenile justice only) FORMCHECKBOX  Termination of court jurisdiction FORMCHECKBOX |~F H P Z b d f h j | ~ ٝzjSz-j h~,hR5CJU\^JaJh~,hR5CJ\^JaJ'jh~,hR5CJU\^JaJ h hBhA3hRhM9hB0J h~,hBhBh ='h`>hshghTyhbq0Jh_h_0J h`>0J hB0Jh~,hSf5B* \ph8V# hT hSfjh&h~,U~H f h j ~ ojeR$Ifgdlk l gdlk gdBpkd $$Ifl|+f, t0644 lap yt~, $Ifgdlk gds&gds&gdg!gdSf          * , . 0 B µȥȡpppppi`Y h hBh#=hB0J h~,hBjhA30JUmHnHuj hA30JU hA30JjhA30JUhA3hBjhR*0JUmHnHuj hR*0JU hR*0JjhR*0JU'jh~,hR5CJU\^JaJ2jh~,hR5CJU\^JaJmHnHu!    , ;6gdBkd* $$Ifl0N,33 t044 lapyt~,$Ifgdlk l $Ifgdlk l $If^gd~,l B D F H J L N P R T r t v         " : < > ʽԶЫʞЫʑЫhA3hB0JjhA30JUjlhA30JU h hBhD h~,hBjF hA30JU hA30JhA3hBjhA30JUmHnHujhA30JUj hA30JU5, T t RMgdBkd $$Ifl0N,33 t044 lapyt~,$Ifgdlk l $Ifgdlk l  " < d f h :5gdA3kd2$$IflF$!N,* t0    44 lapyt~,$Ifgdlk l $Ifgdlk l > R T V X Z \ ^ ` b d f h r t v 4 6 8 : < > 㹽Ŗ h~,hA3hEDhRhM9hA30JjlhA30JUjhA30JUhBhA3hBZ h~,hB h hBjhA30JUmHnHujhA30JUjhA30JU hA30J0h t NIDgdA3gdA3kd$$Ifl0$!N, , }xkL (P$If^gd~,l  (Pgd7OtgdA3okd$$IflPN,f, t044 lap yt~,$IfgdA3l > @ T V X Z \ ^ z | ~      Ӹ璎{wwsws`Q;`+jh~,h0JOJQJU^Jh~,h0JOJQJ^J%jh~,h0JOJQJU^Jh7OthA3jhlk Ujhlk UhWjhWU:jh~,hR5CJOJQJU\^JaJmHnHu5j,h~,hR5CJOJQJU\^JaJ&h~,hR5CJOJQJ\^JaJ/jh~,hR5CJOJQJU\^JaJ " $ & ( * , . 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yt~,$Ifgdlk l Hkd>$$IflN,f, t44 lap yt~,rr r r%r&r'r(r6r7r8r9r]r^r_r`rmrnrorprqrrrrrrrrrrrrrrrrrrrrrrrsss*s+s,s-s;ssdsesfsgsusտմթ՞ՓjFhlk UjEhlk UjChlk Uj_Bhlk UjAhlk Uj?hlk UhA1 h~,h3h3jhA1Ujhlk Uj\>hlk U:^r_rrrr\Hkd B$$IflN,f, t44 lap yt~,$Ifgdlk l Hkd@$$IflN,f, t44 lap yt~,rrrr+s\HkdD$$IflN,f, t44 lap yt~,$Ifgdlk l HkdUC$$IflN,f, t44 lap yt~,+s,sesfss\HkdG$$IflN,f, t44 lap yt~,$Ifgdlk l Hkd-F$$IflN,f, t44 lap yt~,usvswsxsssssssssssssssssտղ՟zaaaa0jh~,hA10JOJQJU^JmHnHu+jLMh~,hA10JOJQJU^Jh~,hA10JOJQJ^J%jh~,hA10JOJQJU^JjxLhlk UUjJhlk UjlIhlk UhA1 h~,h3h3jhA1Ujhlk UjGhlk U&ssss\HkdxJ$$IflN,f, t44 lap yt~,$Ifgdlk l HkdI$$IflN,f, t44 lap yt~, Jurisdiction terminated/unsuccessful treatment (juvenile justice only) FORMCHECKBOX  Other (specify)  FORMTEXT       Information related to the care and supervision of the child or foster care/juvenile justice case/program closure was shared with:  FORMTEXT   FORMCHECKBOX  Legal parent/guardian 1 on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Legal parent/guardian 2 on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Legal guardian on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Provider on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  MDHHS/referring worker on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Youth age 18+ or emancipated on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Court Appointed Special Advocate (CASA) on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Lawyer-guardian ad litem on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email FORMCHECKBOX  Child s attorney on:  FORMTEXT       via  FORMCHECKBOX  In Person  FORMCHECKBOX  Telephone  FORMCHECKBOX  Letter  FORMCHECKBOX  Email Information given to the birth parent, guardian, youth age 18 or older, or youth leaving care due to legal emancipation at case/program closure  FORMTEXT   FORMCHECKBOX  Birth certificate FORMCHECKBOX  Social security card FORMCHECKBOX  DHS-221, Medical Passport FORMCHECKBOX  Education records FORMCHECKBOX  DHS-945, Financial Aid Verification of Court/State Ward Status (youth 13 and older) FORMCHECKBOX  MDHHS-5748, Verification of Placement in Foster Care (youth who were in care at least six months after their 14th birthday) FORMCHECKBOX  Driver s license/state identification (youth 18 and older or emancipated) FORMCHECKBOX  YAVFC fact sheet (youth 18 and older or emancipated) FORMCHECKBOX  DHS-Pub-161, Durable Power of Attorney for Health Care (youth 18 and older or emancipated) FORMCHECKBOX  DHS-Pub-858, Important Information for Youth Transitioning out of Foster Care (youth 18 and older or emancipated) FORMCHECKBOX  Foster Care Transitional Medicaid information (youth 18 and older or emancipated) FORMCHECKBOX  MiHealth card (youth 18 and older or emancipated) FORMCHECKBOX  Medicaid health plan member ID card (youth 18 and older or emancipated who are enrolled in a health plan) Report period:  FORMTEXT       to  FORMTEXT       Summarize services that were provided during care.  FORMTEXT       Summarize services currently being provided.  FORMTEXT       List services and needs still to be met and provisions for follow-up services, if any.  FORMTEXT       Was medical information given to parents or next placement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Date:  FORMTEXT       Was education information given to parents or next placement?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Date:  FORMTEXT       Was closure explained to all parties?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If closure was unplanned, summarize the reasons and circumstances surrounding the closure, including significant events for the child and parents, if applicable, since the last case service plan.  FORMTEXT       section 9  signatures Worker signature Date  FORMTEXT   FORMTEXT      Supervisor signature Date  FORMTEXT       Youth signature (age 18 and older or legally emancipated) Date  FORMTEXT       section 10  distribution list for placement change Complete the distribution list below for all placement changes after the DHS-69 has been approved and signed by the supervisor. The parties below must receive the DHS-69. Indicate N/A if not applicable.  FORMTEXT   FORMCHECKBOX  MDHHS/referring worker on:  FORMTEXT       via  FORMCHECKBOX  Email  FORMCHECKBOX  Mail  FORMCHECKBOX  Fax  FORMCHECKBOX  Hand delivery FORMCHECKBOX  Child s tribe/tribal caseworker on:  FORMTEXT       via  FORMCHECKBOX  Email  FORMCHECKBOX  Mail  FORMCHECKBOX  Fax  FORMCHECKBOX  Hand delivery FORMCHECKBOX  Lawyer-guardian ad litem on:  FORMTEXT       via  FORMCHECKBOX  Email  FORMCHECKBOX  Mail  FORMCHECKBOX  Fax  FORMCHECKBOX  Hand delivery FORMCHECKBOX  Child s attorney on:  FORMTEXT       via  FORMCHECKBOX  Email  FORMCHECKBOX  Mail  FORMCHECKBOX  Fax  FORMCHECKBOX  Hand delivery FORMCHECKBOX  Court of jurisdiction on:  FORMTEXT       via  FORMCHECKBOX  Email  FORMCHECKBOX  Mail  FORMCHECKBOX  Fax  FORMCHECKBOX  Hand delivery AUTHORITY: 1939 PA 280 RESPONSE: Voluntary PENALTY: None Michigan Department of Health and Human Services (MDHHS) Please note if needed, free language assistance services are available. Call  FORMTEXT   FORMTEXT       (TTY  FORMTEXT 711).(Do not type beyond this point) SpanishATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).ArabicED-H8): %0' CF* **-/+ '0C1 'DD:)  A%F ./E'* 'DE3'9/) 'DD:HJ) **H'A1 DC ('DE,'F. '*5D (1BE  REF Phone \* MERGEFORMAT   (1BE G'*A 'D5E H'D(CE:  REF TTY \* MERGEFORMAT 711 ).ChineselaYg`O(uA~Ԛ-Ne `SNMQrs_cR gR0 ˊ  REF Phone \* MERGEFORMAT   TTY  REF TTY \* MERGEFORMAT 711 Syriac (Assyrian)<5*5: 8" 2,?" 9 2!8!<,?" 8+5"5 5,?*55  !5(<,?" )2 <,?" 8 !2,9 22*,5  8+5"5 !25"5<,. )*?" %2  !8"5"5  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711)VietnameseCH : Nu bn ni Ting Vit, c cc dch v h tr ngn ng min ph dnh cho bn. Gi s  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).AlbanianKUJDES: Nse flitni shqip, pr ju ka n dispozicion shrbime t asistencs gjuhsore, pa pages. Telefononi n  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).KoreanX: \m| X” , Ŵ D| 4̸\ tǩX  ǵȲ.  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711)<\ Tt $.Bengali , , d  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).PolishUWAGA: Je|eli mwisz po polsku, mo|esz skorzysta z bezpBatnej pomocy jzykowej. ZadzwoD pod numer  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).GermanACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfgung. Rufnummer  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).ItalianATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711).JapaneselaNe,g0qU0004XT0!qen0/ec0T0)R(uD0_0`0Q0~0Y00  REF Phone \* MERGEFORMAT  TTY  REF TTY \* MERGEFORMAT 711 ~0g00J0qk0f0T0#a}O0`0U0D0Russian: A;8 2K 3>2>@8B5 =0 @CAA:>< O7K:5, B> 20< 4>ABC?=K 15A?;0B=K5 CA;C38 ?5@52>40. 2>=8B5  REF Phone \* MERGEFORMAT   (B5;5B09?  REF TTY \* MERGEFORMAT 711).Serbo-CroatianOBAVJE`TENJE: Ako govorite srpsko-hrvatski, usluge jezi ke pomoi dostupne su vam besplatno. Nazovite  REF Phone \* MERGEFORMAT   (TTY Telefon za osobe sa oateenim govorom ili sluhom  REF TTY \* MERGEFORMAT 711).TagalogPAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa  REF Phone \* MERGEFORMAT   (TTY  REF TTY \* MERGEFORMAT 711). The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person s eligibility. Further, MDHHS: Provides free aids and services to people with disabilities to communicate with us, such as: (( Qualified sign language interpreters (( Written information in other formats (large print, audio, accessible electronic formats, other formats); and Provides free language services to people whose primary language is not English, such as: (( Qualified interpreters (( Information written in other languages If you need these services, contact the Section 1557 Coordinator. The contact information is found below. If you believe that MDHHS has not provided the above services, or discriminated in another way, you can file a grievance with the Section 1557 Coordinator. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you. MDHHS Section 1557 Coordinator Compliance Office, 4th Floor PO Box 30195 Lansing, MI 48909 517-284-1018 (Main), [TTY number if covered entity has one], 517-335-6146 (Fax), [Email] You can also file a civil rights complaint with the responsible federal agency. If your grievance or complaint is about your Medicaid application, benefits or services you can file a civil rights complaint with the U.S. Department of Health and Human Services at https://bit.ly/2pBS4YG, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at https://bit.ly/2IKsHMS.If your grievance or complaint is about your application for or current food assistance benefits, you can file a discrimination complaint with the U.S. Department of Agriculture (USDA) Program by: Completing a Complaint Form, (AD-3027) found online at: https://bit.ly/2g9zzpU or at any USDA office, or write a letter addressed to USDA at the address below. In your letter, provide all the information requested in the form. To request a copy of the complaint form, call 866-632-9992. Send your completed form or letter to USDA by mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 Fax: 202-690-7442; or Email: program.intake@usda.gov MDHHS is an equal opportunity provider. End of form     DHS-69 (Rev. 1-22) Previous edition obsolete.  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DeRClick here if immediate notification was given to MCI superintendent via in person DeRClick here if immediate notification was given to MCI superintendent via telephoneDeOClick here if immediate notification was given to MCI superintendent via letterDeNClick here if immediate notification was given to MCI superintendent via emailDeUClick here if immediate notification was given to Division of Child Welfare Licensing|D If immediate notification was given to Division of Child Welfare Licensing enter the date occurred mm/dd/yyyy Enter N/A if not applicable.DecClick here if immediate notification was given to Division of Child Welfare Licensing via in person.DecClick here if immediate notification was given to Division of Child Welfare Licensing via telephone(De`Click here if immediate notification was given to Division of Child Welfare Licensing via letter&De_Click here if immediate notification was given to Division of Child Welfare Licensing via EmailDeGClick here if immediate notification was given to court of jurisdictionpD If immediate notification was given to court of jurisdiction enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.DeUClick here if immediate notification was given to court of jurisdiction via in personDeUClick here if immediate notification was given to court of jurisdiction via telephone DeRClick here if immediate notification was given to court of jurisdiction via letter DeQClick here if immediate notification was given to court of jurisdiction via Email$$IfT!vh#vf,:V lX t05f,ap yt~,vDText12D&Enter former caseworker's nameD&*Enter former caseworker's telephone number$$IfT!vh#v3:V l t053apyt~,D&%Enter former caseworkers organizationD&(Enter former casewolrker's email address$$IfT!vh#v3:V l t053apyt~,D&Enter new caseworker's nameD&'Enter new caseworker's telephone number$$IfT!vh#v3:V l t053apyt~,D&#Enter new caseworker's organizationD&%Enter new casewolrker's email address$$IfT!vh#v3:V l t053apyt~,vDText12DNEnter parent name$$IfT!vh#vf,:V l t05f,ap yt~,D&Enter former addressDEnter former cityDEnter former stateD Enter former former zip code$$IfT!vh#v8#v #v#vV:V l t0585 55Vap(yt~,D&Enter former telephone numberD&Enter former email address$$IfT!vh#v3:V l t053apyt~,D&Enter new addressDEnter new cityDEnter new stateD Enter new zip code$$IfT!vh#v8#v #v#vV:V l t0585 55Vap(yt~,D&Enter new telephone numberD&Enter new email address$$IfT!vh#v3:V l t053apyt~,$$IfT!vh#vf,:V l t05f,ap yt~,vDText41LDText23kEnter preparation appropriate to the child s capacity to understand has been conducted in the following wayS$$IfT!vh#vf,:V l t5f,ap yt~,pDeCheck6~Click here if information related to transfer from foster care to adoption was shared with MDHHS/referring worker by in persondDe~Click here if information related to transfer from foster care to adoption was shared with MDHHS/referring worker by telephone^De{Click here if information related to transfer from foster care to adoption was shared with MDHHS/referring worker by letter\DezClick here if information related to transfer from foster care to adoption was shared with MDHHS/referring worker by email$$IfT!vh#vf,:V l t05f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText24+Summarize services currently being providedS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~, DText25UList services and needs still to be met and provisions for follow-up services, if any$$IfT!vh#vf,:V l t05f,ap yt~,vDText41DNEnter former placement name$$IfT!vh#vf,:V l t05f,ap yt~,D&Enter former placement addressDEnter former placement cityDEnter former placement stateD Enter former placement zip code$$IfT!vh#v8#v #v#vV:V l t0585 55Vap(yt~,DN'Enter former placement telephone number$$IfT!vh#vf,:V l t05f,ap yt~,DNEnter new placement name$$IfT!vh#vf,:V l t05f,ap yt~,D&Enter new placement addressDEnter new placement cityDEnter new placement stateD Enter new placement zip code$$IfT!vh#v8#v #v#vV:V l t0585 55Vap(yt~,DN$Enter new placement telephone number$$IfT!vh#vf,:V l t05f,ap yt~,DText18GEnter the number of placements for the child since entering foster care$$IfT!vh#vf,:V lP t0,5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,(DText26YDescribe efforts taken to maintain the child s placement and prevent the placement changeS$$IfT!vh#vf,:V l t5f,ap yt~,DeCheck7HClick here if consideration was given to returning the child to a parent DeCheck8LClick here if consideration was not given to returning the child to a parent$$IfT!vh#vf,:V lP t0,5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,~DText27Document reasons why return to a parent would cause a substantial risk of harm to child's life, physical health or mental well-beingS$$IfT!vh#vf,:V l t5f,ap yt~,DBClick here if the child is being placed with a relative or siblingDeFClick here if the child is not being placed with a relative or sibling$$IfT!vh#vf,:V lP t0,5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText28If no, document effots made to place with relative/sibling and reason why placement with relative or sibling is not possible at this timeS$$IfT!vh#vf,:V l t5f,ap yt~,vDText12DeCheck98Click here if the change in placement separates siblingsDeCheck107Click here if the change in placement reunites siblingsDeCheck11:Click here if not applicable because there are no siblingsDeCheck12QClick here if not applicable because all siblings are changing placement together$$IfT!vh#vf,:V l0 t05f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText29GIf any siblings are separated, describe the plan for sibling visitationS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,vDText41DeCheck13MClick here if the foster parent/caregiver has requested the child to be movedS$$IfT!vh#vf,:V l t5f,ap yt~,DeMClick here if the foster parent/caregiver has requested the child to be movedS$$IfT!vh#vf,:V l t5f,ap yt~,BDemClick here if the change in placement is less than 30 calendar days from the child s initial removal from hisS$$IfT!vh#vf,:V l0 t5f,ap yt~,xDeClick here if The change in placement is less than 90 calendar days after the initial placement and the new placement is with a relativeS$$IfT!vh#vf,:V l0 t5f,ap yt~,xDeClick if believed child suffered sexual abuse or non-accidental physical injury or there is risk of harm to child's emotional well beinge$$IfT!vh#vf,:V l(  t 5f,ap yt~, De\Click here if The supervising agency believes it is in the child s best interest to be movedS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText30DBriefly describe the circumstances that lead to the placement changeS$$IfT!vh#vf,:V l t5f,ap yt~,a$$IfT!vh#vf,:V l0 t5f,/ ap yt~,vDText12&DText19XEnter placement criteria ranking for the case plan which includes the goal of permanenceS$$IfT!vh#vf,:V l t5f,ap yt~,DXEnter placement criteria rank for the physical, emotional, and safety needs of the childS$$IfT!vh#vf,:V l t5f,ap yt~,DDEnter placement criteria ranking for proximity to the child s familyS$$IfT!vh#vf,:V l t5f,ap yt~, DQEnter placement criteria ranking for placement within the relative family networkS$$IfT!vh#vf,:V l t5f,ap yt~,D<Enter placement criteria ranking for placement with siblingsS$$IfT!vh#vf,:V l t5f,ap yt~,DTEnter placement criteria ranking for the least-restrictive, most family-like settingS$$IfT!vh#vf,:V l t5f,ap yt~,DDEnter placement criteria ranking for the continuity of relationshipsS$$IfT!vh#vf,:V l t5f,ap yt~,DZEnter placement criteria ranking for the child s and child s family s religious preferenceS$$IfT!vh#vf,:V l t5f,ap yt~,DTEnter placement criteria ranking for the child s expressed preferences for placementS$$IfT!vh#vf,:V l t5f,ap yt~,~DEnter criteria ranking for appropriateness of childs current educational setting/proximity to school child was enrolled at time of removalS$$IfT!vh#vf,:V l t5f,ap yt~,BDlEnter placement criteria ranking for availability of placement resources for the purpose of timely placementS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText31=If any placement selection criteria were not met, explain whyS$$IfT!vh#vf,:V l t5f,ap yt~,DeGClick here if the change in places requires the child to change schoolsDeOClick here if the change in places does not require the child to change schools$$IfT!vh#vf,:V l t0,5f,ap yt~,S$$IfT!vh#vf,:V l t5f,ap yt~,rDText32~If change in placement require child to change schools, describe the efforts to maintain the child in his/her school of originS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V lX t05f,ap yt~,XDText33qDescribe how the child, parent(s), previous placement, and new placement were prepared for the placement change. S$$IfT!vh#vf,:V l t5f,ap yt~,|DeClick if child is an Indian Child defined in MCL 712b.3(k) If yes, choose active effots to place the child in compliance MCL 712B.23 belowDeGClick here if the child is not an Indian Child defined in MCL 712b.3(k)S$$IfT!vh#vf,:V l t5f,ap yt~,S$$IfT!vh#vf,:V l t5f,ap yt~,nDeClick here if engaging indian child/parents/tribe/extended family/caregivers through utilization of culturally appropriate services$$IfT!vh#vf,:V l t05f,/ ap yt~,bDe}Click here if identifying appropriate services and helping the parents to overcome barriers to compliance with those services$$IfT!vh#vf,:V l t05f,/ ap yt~,FDeoClick here if conducting or causing to be conducted a diligent search for extended family members for placement$$IfT!vh#vf,:V l t05f,/ ap yt~,DeOClick here if requesting representatives designated by the Indian child's tribe$$IfT!vh#vf,:V l t05f,/ ap yt~,*DeaClick here if completing a comprehensive assessment of the siutation of the Indian child's family$$IfT!vh#vf,:V l t05f,/ ap yt~,|DeClick here if identifying notifying inviting representatives of Indian childs tribe to participate in all aspects of Indian child custody $$IfT!vh#vf,:V l t05f,/ ap yt~,|DeClick here if notifying/consulting with extended Indian child family to identify and provide family structure and support for Indian child$$IfT!vh#vf,:V l t05f,/ ap yt~,jDeClick here if making arrangements to provide natural & family interaction in most natural setting to ensure Indian child's safety$$IfT!vh#vf,:V l t05f,/ ap yt~,fDeClick here if offering & employing all available family preervations strategies & requesting involvement of Indian childs tribe$$IfT!vh#vf,:V l t05f,/ ap yt~,|DeClick here if identify community resources offer housing financial & transportation assistance for indian childs family with special needs$$IfT!vh#vf,:V l t05f,/ ap yt~,DeMClick here if monitoring client progress and client participation in services$$IfT!vh#vf,:V l t05f,/ ap yt~,bDe}Click here if providing consideration of alternative ways addressing needs of Indian child's family if services do not exist$$IfT!vh#vf,:V l t05f,/ ap yt~,DeClick here if other$$IfT!vh#vf,:V l t05f,/ ap yt~,DText34Enter other text hereS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,$$IfT!vh#vf,:V lP t05f,/ ap yt~,vDText12DeSClick here If placement change notification was provided to legal parent/guardian 1nD If placement change was provided to legal parent/guardian 1 enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.$De^Click here if placement change notification was given to legal parent/guardian 1 via in person$De^Click here if placement change notification was given to legal parent/guardian 1 via telephoneDeZClick here if placement change notification was given to legal parent/guardian 1 via emailDe[Click here if placement change notification was given to legal parent/guardian 1 via DHS-69$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeSClick here If placement change notification was provided to legal parent/guardian 2nD If placement change was provided to legal parent/guardian 2 enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.$De^Click here if placement change notification was given to legal parent/guardian 2 via in person$De^Click here if placement change notification was given to legal parent/guardian 2 via telephoneDeZClick here if placement change notification was given to legal parent/guardian 2 via emailDe[Click here if placement change notification was given to legal parent/guardian 2 via DHS-69$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeSClick here If placement change notification was provided to MDHHS/referring worker*nD If placement change was provided to MDHHS/referring worker* enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.$De^Click here if placement change notification was given to MDHHS/referring worker* via in person$De^Click here if placement change notification was given to MDHHS/referring worker* via telephoneDeZClick here if placement change notification was given to MDHHS/referring worker* via emailD[Click here if placement change notification was given to MDHHS/referring worker* via DHS-69$$IfT!vh#vf,:V lh t05f,ap yt~, De\Click here If placement change notification was provided to child's tribe/tribal caseworker*~D If placement change was provided to child's tribe/tribal caseworker* enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable6DegClick here if placement change notification was given to child's tribe/tribal caseworker* via in person6DegClick here if placement change notification was given to child's tribe/tribal caseworker* via telephone.DecClick here if placement change notification was given to child's tribe/tribal caseworker* via email0DedClick here if placement change notification was given to child's tribe/tribal caseworker* via DHS-69$$IfT!vh#vf,:V lh t05f,ap yt~,DOClick here If placement change notification was provided to MCI superintendent dD }If placement change was provided to MCI superintendent enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.DeYClick here if placement change notification was given to MCI superintendent via in personDeYClick here if placement change notification was given to MCI superintendent via telephoneDeUClick here if placement change notification was given to MCI superintendent via emailDeVClick here if placement change notification was given to MCI superintendent via DHS-69$$IfT!vh#vf,:V lh t05f,ap yt~,DeVClick here If placement change notification was provided to lawyer-guardian ad litem* rD If placement change was provided to lawyer-guardian ad litem* enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.(De`Click here if placement change notification was given to lawyer-guardian ad litem* via in person(De`Click here if placement change notification was given to lawyer-guardian ad litem* via telephone De\Click here if placement change notification was given to lawyer-guardian ad litem* via email"De]Click here if placement change notification was given to lawyer-guardian ad litem* via DHS-69$$IfT!vh#vf,:V lh t05f,ap yt~,DeNClick here If placement change notification was provided to child's attorney* bD |If placement change was provided to child's attorney* enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.DeXClick here if placement change notification was given to child's attorney* via in personDeXClick here if placement change notification was given to child's attorney* via telephoneDeTClick here if placement change notification was given to child's attorney* via emailDeUClick here if placement change notification was given to child's attorney* via DHS-69$$IfT!vh#vf,:V lh t05f,ap yt~,DeSClick here If placement change notification was provided to court of jurisdiction* lD If placement change was provided to court of jurisdiction* enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable."De]Click here if placement change notification was given to court of jurisdiction* via in person"De]Click here if placement change notification was given to court of jurisdiction* via telephoneDeYClick here if placement change notification was given to court of jurisdiction* via emailDeZClick here if placement change notification was given to court of jurisdiction* via DHS-69$$IfT!vh#vf,:V lh t05f,ap yt~,DeOClick here If placement change notification was provided to previous placement dD }If placement change was provided to previous placement enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.DeYClick here if placement change notification was given to previous placement via in personDeYClick here if placement change notification was given to previous placement via telephoneDeUClick here if placement change notification was given to previous placement via emailDeVClick here if placement change notification was given to previous placement via DHS-30$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeJClick here If placement change notification was provided to new placement ZD xIf placement change was provided to new placement enter the date this occurred (mm/dd/yyyy) Enter N/A if not applicable.DeTClick here if placement change notification was given to new placement via in personDeTClick here if placement change notification was given to new placement via telephoneDePClick here if placement change notification was given to new placement via emailDeSClick here if placement change notification was given to new placement via DHS-3307$$IfT!vh#vf,:V lh t05f,/ / ap yt~,vDText12DeCheck14&Click here if temporary break is AWOLPDeCheck15HClick here if temporary break is hospitalization (medical/psychiatric) DeCheck16%Click here if temporary break is jailDeCheck17,Click here if temporary break is detention $$IfT!vh#vf,:V l0 t05f,ap yt~,DeGClick here if the child is expected to return to the previous placementDeKClick here if the child is not expected to return to the previous placement$$IfT!vh#vf,:V lP t0,5f,ap yt~,S$$IfT!vh#vf,:V l t5f,ap yt~,dDText35wIf child not expected to return to previous placement, why and what is the plan for placement after the temporary breakS$$IfT!vh#vf,:V l t5f,ap yt~,DeJClick here if there is an estimated length of time for the temporary breakDeNClick here if there is not an estimated length of time for the temporary break$$IfT!vh#vf,:V lP t0,5f,ap yt~,S$$IfT!vh#vf,:V l t5f,ap yt~,rDText36~If there is estimate length of time for temporary break, estiamte length of break. If not, explay why no estimate is available$$IfT!vh#vf,:V l t05f,ap yt~,a$$IfT!vh#vf,:V l t5f,/ ap yt~,vDText12DeCheck189Click here if program type that is closing is foster careDeCheck19>Click here if program type that is closing is juvenile justiceS$$IfT!vh#vf,:V l t5f,ap yt~,S$$IfT!vh#vf,:V l t5f,ap yt~,vDText12DeCheck20LClick here if reason for case/program closure is age (emancipation/aged out)S$$IfT!vh#vf,:V l t5f,ap yt~,De6Click here if reason for case/program closure is AWOLPS$$IfT!vh#vf,:V l t5f,ap yt~,DeKClick here if reason for case/program closure is married (foster care only)S$$IfT!vh#vf,:V l t5f,ap yt~,DeTClick here if reason for case/program closure is military service (foster care only)S$$IfT!vh#vf,:V l t5f,ap yt~,DeGClick here if reason for case/program closure is moved to another stateS$$IfT!vh#vf,:V l t5f,ap yt~,DeGClick here if reason for case/program closure is OTI activity completedS$$IfT!vh#vf,:V l t5f,ap yt~,DeWClick here if reason for case/program closure is placed for adoption (foster care only)S$$IfT!vh#vf,:V l t5f,ap yt~,DeXClick here if reason for case/program closure is placed with guardian (foster care only)S$$IfT!vh#vf,:V l t5f,ap yt~,DeVClick here if reason for case/program closure is placed with parent (foster care only)S$$IfT!vh#vf,:V l t5f,ap yt~,,DebClick here if reason for case/program closure is escalated to adult system (juvenile justice only)S$$IfT!vh#vf,:V l t5f,ap yt~, DeRClick here if reason for case/program closure is termination of court jurisdictionS$$IfT!vh#vf,:V l t5f,ap yt~,VDewClick here if reason for case/program closure is jurisdiction terminated/unsuccessful treatment (juvenile justice only)S$$IfT!vh#vf,:V l t5f,ap yt~,De6Click here if reason for case/program closure is otherDText20HIf checked other enter what the other reason for case/program closure isS$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,vDText12DeAClick here If information was shared with legal parent/guardian 1*D `If information was shared with legal parent/guardian 1 enter the date this occurred (mm/dd/yyyy)DeOClick here if information was shared with legal parent/guardian 1 via in person DeRClick here if if information was shared with legal parent/guardian 1 via telephoneDeOClick here if if information was shared with legal parent/guardian 1 via letterDeKClick here if information was shared with legal parent/guardian 1 via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeAClick here If information was shared with legal parent/guardian 2*D `If information was shared with legal parent/guardian 2 enter the date this occurred (mm/dd/yyyy)DeOClick here if information was shared with legal parent/guardian 2 via in person DeRClick here if if information was shared with legal parent/guardian 2 via telephoneDeOClick here if if information was shared with legal parent/guardian 2 via letterDeKClick here if information was shared with legal parent/guardian 2 via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,De9Click here If information was shared with Legal guardian D WIf information was shared with Legal guardian enter the date this occurred (mm/dd/yyyy)DeFClick here if information was shared with Legal guardian via in personDeIClick here if if information was shared with Legal guardian via telephoneDeFClick here if if information was shared with Legal guardian via letterDeBClick here if information was shared with Legal guardian via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,De3Click here If information was shared with Provider D QIf information was shared with Provider enter the date this occurred (mm/dd/yyyy)De@Click here if information was shared with Provider via in personDeCClick here if if information was shared with Provider via telephoneDe@Click here if if information was shared with Provider via letterDe<Click here if information was shared with Provider via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeAClick here If information was shared with MDHHS/referring worker (D _If information was shared with MDHHS/referring worker enter the date this occurred (mm/dd/yyyy)DeNClick here if information was shared with MDHHS/referring worker via in person DeQClick here if if information was shared with MDHHS/referring worker via telephoneDeNClick here if if information was shared with MDHHS/referring worker via letterDeJClick here if information was shared with MDHHS/referring worker via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeFClick here If information was shared with Youth age 18+ or emancipated4D eIf information was shared with Youth age 18+ or emancipated enter the date this occurred (mm/dd/yyyy)DeTClick here if information was shared with Youth age 18+ or emancipated via in personDeWClick here if if information was shared with Youth age 18+ or emancipated via telephoneDeTClick here if if information was shared with Youth age 18+ or emancipated via letterDePClick here if information was shared with Youth age 18+ or emancipated via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeJClick here If information was shared with Court Appointed Special Advocate<D iIf information was shared with Court Appointed Special Advocate enter the date this occurred (mm/dd/yyyy)DeXClick here if information was shared with Court Appointed Special Advocate via in personDe[Click here if if information was shared with Court Appointed Special Advocate via telephoneDeXClick here if if information was shared with Court Appointed Special Advocate via letterDeTClick here if information was shared with Court Appointed Special Advocate via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,DeBClick here If information was shared with Lawyer-guardian ad litem,D aIf information was shared with Lawyer-guardian ad litem enter the date this occurred (mm/dd/yyyy)DePClick here if information was shared with Lawyer-guardian ad litem via in personDeSClick here if if information was shared with Lawyer-guardian ad litem via telephoneDePClick here if if information was shared with Lawyer-guardian ad litem via letterDeLClick here if information was shared with Lawyer-guardian ad litem via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,De:Click here If information was shared with Child s attorneyD YIf information was shared with Child s attorney enter the date this occurred (mm/dd/yyyy)DeHClick here if information was shared with Child s attorney via in personDeKClick here if if information was shared with Child s attorney via telephoneDeHClick here if if information was shared with Child s attorney via letterDeDClick here if information was shared with Child s attorney via email$$IfT!vh#vf,:V lh t05f,/ ap yt~,a$$IfT!vh#vf,:V l t5f,/ ap yt~,vDText12DeCheck214Click here if information given is birth certificateS$$IfT!vh#vf,:V lP t5f,ap yt~,DeCheck227Click here if information given is Social security cardS$$IfT!vh#vf,:V lP t5f,ap yt~,De<Click here if information given is DHS-221, Medical PassportS$$IfT!vh#vf,:V lP t5f,ap yt~,De4Click here if information given is Education recordsS$$IfT!vh#vf,:V lP t5f,ap yt~,TDevClick here if information given is DHS-945, Financial Aid Verification of Court/State Ward Status (youth 13 and older)S$$IfT!vh#vf,:V lP t5f,ap yt~,|DeClick here if information given is MDHHS-5748, Verification of Placement in Foster Care (youth in care at least 6 months after 14 birthdayS$$IfT!vh#vf,:V l0 t5f,ap yt~,BDemClick here if information given is Driver s license/state identification (youth 18 and older or emancipated) S$$IfT!vh#vf,:V lP t5f,ap yt~,DeXClick here if information given is YAVFC fact sheet (youth 18 and older or emancipated) S$$IfT!vh#vf,:V lP t5f,ap yt~,dDe~Click here if information given is DHS-Pub-161, Durable Power of Attorney for Health Care (youth 18 and older or emancipated) S$$IfT!vh#vf,:V lP t5f,ap yt~,|DeClick here if information given is DHS-Pub-858 Important Information for Youth Transitioning out of Foster Care youth 18 & older/emancipatS$$IfT!vh#vf,:V l0 t5f,ap yt~,RDeuClick here if information given is Foster Care Transitional Medicaid information (youth 18 and older or emancipated) S$$IfT!vh#vf,:V lP t5f,ap yt~,DeUClick here if information given is MiHealth card (youth 18 and older or emancipated) S$$IfT!vh#vf,:V lP t5f,ap yt~,|DeClick here if information given is Medicaid health plan member ID card (youth 18 & older or emancipated who are enrolled in a health plan)S$$IfT!vh#vf,:V lx t5f,ap yt~,DText21.Enter begin date of report period (mm/dd/yyyy)D,Enter end date of report period (mm/dd/yyyy)$$IfT!vh#vf,:V lP t0,5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText371Summarize services that were provided during careS$$IfT!vh#vf,:V l t5f,ap yt~,S$$IfT!vh#vf,:V l t5f,ap yt~,DText38,Summarize services currently being provided.S$$IfT!vh#vf,:V l t5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~, DText39UList services and needs still to be met and provisions for follow-up services, if anyS$$IfT!vh#vf,:V l t5f,ap yt~,DeHClick here if medical information was given to parents or next placementDeLClick here if medical information was not given to parents or next placementDText22REnter date medical information was given to parents or next placement (mm/dd/yyyy)$$IfT!vh#vf,:V lP t0,5f,ap yt~, DeCheck23JClick here if education information was given to parents or next placementDeCheck24NClick here if education information was not given to parents or next placementDTEnter date education information was given to parents or next placement (mm/dd/yyyy)$$IfT!vh#vf,:V lP t0,5f,ap yt~,De2Click here if closure was explained to all partiesDe6Click here if closure was not explained to all parties$$IfT!vh#vf,:V lP t0,5f,ap yt~,$$IfT!vh#vf,:V l t05f,ap yt~,DText40If closure was unplanned summarize reasons/circumstances surrounding closure including events for child & parents since last case service $$IfT!vh#vf,:V l t05f,ap yt~,vDText12D +Enter date of worker signature (mm/dd/yyyy)D /Enter date of supervisor signature (mm/dd/yyyy)$$IfT!vh#v#vr#v#vz:V l t055r55zap(yt~,D GEnter date of youth signature (age 18 and older or legally emancipated)$$IfT!vh#v%#vz:V l t05%5zapyt~,$$IfT!vh#vf,:V l t05f,/ ap yt~,vDText12DD6Click here for MDHHS/referring worker receiving DHS-698Click here if DHS-69 was sent to MDHHS/referring worker D ^Enter date MDHHS/referring worker sent the DHS-69. Indicate N/A if not applicable (mm/dd/yyyy)jEnter the date the DHS-69 was sent to MDHHS/referring worker (mm/dd/yyyy). Indicate N/A if not applicableD Click here ifCClick here if DHS-69 was sent to MDHHS/referring worker via email DeAClick here if DHS-69 was sent to MDHHS/referring worker via mailDe?Click here if DHS-69 was sent to MDHHS/referring worker via faxDeIClick here if DHS-69 was sent to MDHHS/referring worker via hand delivery$$IfT!vh#vf,:V lh t05f,/ ap yt~,fD?Click here for child's tribe/tribal caseworker receiving DHS-69@Click here if DHS-69 was sent to child's tribe/tribal caseworkerD gEnter date child's tribe/tribal caseworker sent the DHS-69. Indicate N/A if not applicable (mm/dd/yyyy)sEnter the date the DHS-69 was sent to child's tribe/tribal caseworker (mm/dd/yyyy). Indicate N/A if not applicableDeLClick here if DHS-69 was sent to child's tribe/tribal caseworker via email DeIClick here if DHS-69 was sent to child's tribe/tribal caseworker via mailDeHClick here if DHS-69 was sent to child's tribe/tribal caseworker via fax DeRClick here if DHS-69 was sent to child's tribe/tribal caseworker via hand delivery$$IfT!vh#vf,:V lh t05f,/ ap yt~,JD8Click here for lawyer-guardian ad litem receiving DHS-699Click here if DHS-69 was sent to lawyer-guardian ad litemD `Enter date lawyer-guardian ad litem sent the DHS-69. Indicate N/A if not applicable (mm/dd/yyyy)lEnter the date the DHS-69 was sent to lawyer-guardian ad litem (mm/dd/yyyy). Indicate N/A if not applicableDeEClick here if DHS-69 was sent to lawyer-guardian ad litem via email DeBClick here if DHS-69 was sent to lawyer-guardian ad litem via mailDeAClick here if DHS-69 was sent to lawyer-guardian ad litem via faxDeKClick here if DHS-69 was sent to lawyer-guardian ad litem via hand delivery$$IfT!vh#vf,:V lh t05f,/ ap yt~,*D0Click here for child's attorney receiving DHS-691Click here if DHS-69 was sent to child's attorneyD XEnter date child's attorney sent the DHS-69. Indicate N/A if not applicable (mm/dd/yyyy)dEnter the date the DHS-69 was sent to child's attorney (mm/dd/yyyy). Indicate N/A if not applicableDe=Click here if DHS-69 was sent to child's attorney via email De:Click here if DHS-69 was sent to child's attorney via mailDe9Click here if DHS-69 was sent to child's attorney via faxDeCClick here if DHS-69 was sent to child's attorney via hand delivery$$IfT!vh#vf,:V lh t05f,/ ap yt~,>D5Click here for court of jurisdiction receiving DHS-696Click here if DHS-69 was sent to court of jurisdictionD ]Enter date court of jurisdiction sent the DHS-69. Indicate N/A if not applicable (mm/dd/yyyy)iEnter the date the DHS-69 was sent to court of jurisdiction (mm/dd/yyyy). Indicate N/A if not applicableDeBClick here if DHS-69 was sent to court of jurisdiction via email De?Click here if DHS-69 was sent to court of jurisdiction via mailDe>Click here if DHS-69 was sent to court of jurisdiction via faxDeHClick here if DHS-69 was sent to court of jurisdiction via hand delivery$$IfT!vh#vf,:V lh t05f,/  / ap yt~,d$$If\!vh#vf,:V l8 t65f,/ ap yt~,vDText42DAPhone@Enter the telephone number for free language assistance servicesvDTTY711S$$IfT!vh#vf,:V l` t5f,ap yt~,$$Ifq!vh#v #v!:V l t0+65 5!/ pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V l t0+65 5!pyt~,T$$Ifq!vh#v #v!:V lF t0+65 5!pyt~,T$$Ifq!vh#v#vY:V ly t0655Ypyt~,"&x 666666666vvvvvvvvv66666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2 &6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv0XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666$OJ PJ QJ ^J_HmH nH sH tH J`J BZNormal dCJ_HaJmH sH tH ^^ s& Heading 3$d<@&5CJOJPJQJ^JaJDA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List `O` s&Form Title 12ptda$CJOJPJQJ^JaJ`O` s&Form Title 13ptda$CJOJPJQJ^JaJlOl s&Form Title 14pt Bldda$;CJOJPJQJ^JaJd/!d s&Form Title 14pt Bld Char;CJOJPJQJ^JaJV@2V s&HeaderdH$CJOJPJQJ^JaJF/AF s& Header CharCJOJPJQJ^JaJP/QP s&Heading 3 Char5CJOJPJQJ^JaJjObj s&Letter Text 12ptd]^CJOJPJQJ^JaJhOrh s&User Input 12ptd]^CJOJPJQJ^JaJt`t s&p Table Grid7:V0 dFOaF s&Section Heading <<;`o` s& Line Spacerd'5CJOJPJQJ^J_HmH sH tH *W`* s&`Strong5\> @> s&0FooterdH$.. s&0 Footer CharFV F s&0FollowedHyperlink >*B*phOr6U 6 s&0 Hyperlink >*B*phcRv!R s&0Unresolved MentionB*ph`^\q NO1N"SfADA Note!a$<CJPJ^JaJmHnHuP/!P!Sf ADA Note Char<CJPJ^JaJmHnHuH`2H Sf No Spacing#CJ_HaJmH sH tH vov k[p Table Grid17:V$0 $dvov k[p Table Grid27:V%0 %dPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y s;, _ ^_/I1d88%;;;7<??EFsNNLOMPST`7k5575n5555P555525l5555N555505g5555I5555+5e555 5D5~555)5` ]_aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaad B > >  "6vNb 8h !"#,$>%"&'B)++,-.j03r5b7p8<>@A^DEFIJ-PeVY[\^:_J`abcdfADEGHIKLMPQSTUVWXY[]_bdgimosuw{} "%(,.257;=ABDFGIKMOQTVX[]^_dgkmp , h , vT X!!"##$$%4&T&'()"*R*,++,--../D0r0224 5b778F:;$=R=f?\@.AB*CEEFFG@InItJLLoNiOPQeSqTQVVpWWX^[\R^_8abddef,hijl mnnppq^rr+ss X  v^NR$Rh,Hp(P08zbzP$V;=?@BCFJNORZ\^`acefhjklnpqrtvxyz|~ !#$&')*+-/0134689:<>?@CEHJLNPRSUWYZ\`abcefhijlno"(:FL\hn}+-.>?]ioq)5;=MN]io9EKdpv;GIJZ[t  (.4DEQabn~   " 2 3 < L M U e f    3 ? 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"""t"""###$($)$$$$p&&&j'z'{'((()**f+v+w+r,,,R.b.c....q//////I1U1W1X1h1i1111111111111122 222<2H2N2T2d2e2q222222222222223 333&36373C3S3T3\3l3m3w3333333333334444*4+454E4F4_4k4q4w4444444444444445"5(5.5>5?5K5[5\5h5x5y55555555555555 6 66'6(606@6A6K6[6\6y666666666666666677)757;7A7Q7R7^7n7o7{777777777777777 888&86878?8O8P88888888888 9 99"9#9l9|9}9999:+:1:s::::::;;!;;;;;;;;;;7<C<E<F<V<W<v<<<<<<<<<<=="=2=3=M=]=^========>>D>T>U>z>>>>>>>? ?????????????@@@$@4@5@>@N@O@X@h@i@@@@@@@@@@@@@@AA AAA3A?AEAKA[A\AhAxAyAAAAAAAAAAAAAABBBBB+B;BE?EHEXEYEpE|EEEEEEEEEEEEEEFFFFFFFFFFFFG&G'GMhMxMyMMMM]NiNoNNNNNNNNNN6OBOHOMPYP[P\PlPmPPPPPPPPPPPPPPPP QQQCQOQUQ[QkQlQtQQQQQQQQQQQQQRR RRR&R6R7R>RNRORUReRfRwRRRRRRRRRRRRRRRRSS!S1S2SNSZS`SfSvSwSSSSSSSSSSTTTTTTTTTgUUUUUUV4V:VSVnVrVVVVVVVWWWWWW?X\XbXiXXXY"Y(Y/YJYNYYYYYYYSZpZvZZZZ[,[2[9[T[X[[[[\ \$\\\\\\]2]O]U][]v]z]]^^&^A^E^^^^_5_9_____` `7kFFFFFFFFFFFGFGFGFGFGFGFGFGFFFFFFFFFGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGFFFFFFFFFFFFFFFFFFFFFFFFFGGGGFFFFFFFFFFFFFFFFFGGFGGFFGGGGFFGGGGGGFFFFFFFFFFFFFFGGFFGGGGGGGGGGGGGGGFFGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGFGGGGGGFGGFFGGFGGGGGGGGGGGGGFFGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGFGGGGGGGGGGGGGFFFFFGGFGGFGGFFFFFFGFGGGGGFGGGGGFGGGGGFGGGGGFGGGGFFF@XZd!T # @ 0(  B S  ?H0(  ;Check1Text13Check2Text14Text15Text16Check3Text17Check4Check5Text23Check6Text24Text25Text18Text26Check7Check8Text27Text28Check9Check10Check11Check12Text29Text41Check13Text30Text19Text31Text32Text33Text34Check14Check15Check16Check17Text35Text36Check18Check19Check20Text20Check21Check22Text21Text37Text38Text39Text22Check23Check24Text40 _Hlk81401209Text42PhoneTTY _Hlk81399774 _Hlk81399819/:eKuv%wd|&)o !/8889 :;;;G<>FF KmKK!LLLM^NTTTTT`8k  !"#$%&'()*+,-./0123485679:@Lw\  &7v7(:} !/88 9$92:";;;X< ?FFKKK3LL M"MpNTTTT`j8k^UcUgUUUUV;VSVsVVVVVVVWWWW8X;XX?XcXiXXY)Y/YOYZY\Y^YbYcYhYiYkYmYoYpYrYsYwYxY{Y|YYYYYYYYYYYYYYSZwZZZZ[ [[[3[9[Y[[[[[\%\\\\\\\\]]0]2]V][]{]]]]^^%^&^F^^^^^^^_______:________ `jjjjjjjjj5k8k**--/F2FgUUUUV;VSVsVVVVVWWWW?XcXiXXY)Y/YOYYYYYSZwZZZ[3[9[Y[[[\%\\\\]2]V][]{]]^&^F^^^_:____ `GfOfjjjjjjjjj5k8k';:\OJ PJ QJ ^J o(" ^`OJQJ^Jo(o p^p`OJ QJ o( @ ^@ `OJQJo(^`OJQJ^Jo(o ^`OJ QJ o( ^`OJQJo(^`OJQJ^Jo(o P^P`OJ QJ o(';ҭ        g_ =`lk %6 u; \> _ 2HU" NuA1%#0%BL} Y6& #$s& ='()))R*,),~,&/862A3%+4V4 v4{4w8 8-89M9kx9):D>`>W@ED.InI~L:P}jVXWXBZwEZ\[k[1\: ]V<_Ws_4dPf hSik'n'rs-`s7Otv U{Z|p}_~H/}FW+HhSfBW< rd`qw Ty WG Zkm26Q`97V(E>;g*uDu]}U?L h$XCP3bq,s0UYcLTB@ RM bLFX6s#9Rjj@   !"/023456789:;<>7kPP P PPPPPPP P"P$P&P(P*P,P.P0P2P4P6P8Pt@P<P>P@PBPDPFPHP@PXPZP^P`PbPdPfPhPjPlPnPpP@PUnknownG.[x Times New Roman5Symbol3. .[x Arial?= .Cx Courier New=Arial BoldK=   jMS Gothic-3 0000K. `Segoe UI HistoricY AssyrianTimes New RomanC. /|)Malgun Gothic=. #JNirmala UI5.Vrinda7..{$ CalibriC.,.{$ Calibri Light;WingdingsA$BCambria Math"1h@\D\⡧Z 6Z 6!0jjJ@P  $P~,*!xx+; 2DHS-69 Foster Care/Juvenile Justice Action Summary+Foster Care/Juvenile Justice Action Summary8MDHHS;DHS-69;foster care;juvenile justice;action summary0Michigan Department of Health and Human ServicesSimmons, Scott (DTMB) Oh+'0T     ,8@HPX4DHS-69 Foster Care/Juvenile Justice Action Summary,Foster Care/Juvenile Justice Action Summary4Michigan Department of Health and Human Services<MDHHS;DHS-69;foster care;juvenile justice;action summary844c10069.dotxSimmons, Scott (DTMB)1Microsoft Office Word@ @w`@̶@E ZGVT$m IMw  0."System- "SystemY j7-"System--@Times New Roman---  2 0    0''@"Arial--- 2 0 DHS   2 >0 - 2 C0 69   2 U0   2 Y0 (Rev.    2 0 1   2 0 - 2 0 22  2  0 ) Previous     %2 0 edition obsolete.        2 d0  5  2 0 1   2 0    0''@"Arial--- 2 .y0 DHS   2 .0 - 2 .0 69  2 .0 ,  L2 .+0 FOSTER CARE/JUVENILE JUSTICE ACTION SUMMARY              2 .0   @"Arial--- S2 B00 Michigan Department of Health and Human Services               2 Bb0   --- 2 Uc0 (Rev  2 U0 ised    2 U0 1   2 U0 - 2 U0 22   2 U0 )  2 U0   l i  2 zi l  ' - @ !l-   @"Arial------ 2  0 SECTION 1     2 p0   --- 2 Case name     2 s  @1Courier New---@1Courier New- - - @1Courier New- - - ---- - - ---  2  - - -   2 !   2 +   2 5   2 >   2 H - - -   2 Q  '--- 2 Case ID     2   - - - - - -   2    2    2    2    2  - - -   2   '- @ !{- - @ !-- @ !x-    @Arial Bold- - -   2 0   --- 2 Child name     2 s  - - - - - -   2    2 *   2 4   2 =   2 G - - -   2 P  '--- "2 Child person ID       2   - - - - - -   2    2    2    2    2  - - -   2   '- @ !{- - @ !-- @ !z-    - - -   2 0    7--- 2 7 Worker name     2 7   - - - - - -   2  7    2 *7    2 47    2 =7    2 G7  - - -   2 P7   ' R7--- 2 < 7R Organization      2 7R   - - -   2 <7R    2 F7R    2 P7R    2 Y7R    2 c7R    2 l7R   ' R--- 2 X R Phone number    2 R   - - - - - -   2 XR    2 bR    2 lR    2 uR    2 R  - - -   2 R   '- @ !- - @ !7-- @ !8- - @ !S-- @ !T-     - - -   2 0   4R --- 2 " R4Email   2 K R4  - - - - - -   2 -  R4   2 -* R4   2 -4 R4   2 -= R4   2 -G R4 - - -   2 -P R4  '4 R---  2 ZR 4Date completed       2 R 4  - - - - - -   2 -XR 4   2 -bR 4   2 -lR 4   2 -uR 4   2 -R 4 - - -   2 -R 4  '- @ !8 - - @ ! S-- @ ! T-    - - -   2 50   R6--- D2 J &6RType of action (check as many as apply            2 J:6R)  2 J?6R  '- @ !5-   - - -   2 S0   S------- - - ------  2 e S  S--- S '- - f1W"-- '---  2 e3S  P2 e7.SChild fatality notification (complete section              2 efS2   2 eoS) ;2 et S................................ #2 eS................ #2 e4SEffective Date:     - - -   2 eS   2 eS   2 eS   2 eS   2 eS   2 eS  S''---- - -  S--- S '- - 0p!-- '---  2 ~2S  Y2 ~64SCaseworker/organization change (complete section 3)                2 ~S  82 ~S.............................. #2 ~4SEffective Date:     - - -   2 ~S   2 ~S   2 ~S   2 ~S   2 ~S ---  2 ~S  S''- - -  S--- S '- - 0!-- '---  2 2S  ^2 67SParent contact information change (complete section 4)                 2 S  52 S............................ #2 4SEffective Date:     - - -   2 S   2 S   2 S   2 S   2 S ---  2 S  S''- - -  S--- S '- - 0!-- '---  2 2S  \2 66SFoster care transfer to adoption (complete section 5)                 2 S  ;2  S................................  2 0S. #2 4SEffective Date:     - - -   2 S   2 S   2 S   2 S   2 S ---  2 S  S''- - -  S--- S '- - 0!-- '---  2 2S  D2 6&SPlacement change (complete section 6)           ;2 T S................................ /2 S........................ #2 4SEffective Date:     - - -   2 S   2 S   2 S   2 S   2 S ---  2 S  S''- - -  S--- S '- - 0!-- '---  2 2S  C2 6%STemporary break (complete section 7)            2 IS  ;2 L S................................ 22 S.......................... #2 4SEffective Date:     - - -   2 S   2 S   2 S   2 S   2 S ---  2 S  S''- - -  S--- S '- - 0!-- '---  2 2S  U2 61SFoster care program closure (complete section 8)                  2 S  ;2  S................................ 2 S...... #2 4SEffective Date:     - - -   2 S   2 S   2 S   2 S   2 S ---  2 S  S''- - -  S--- S '- - 0!-- '---  2 2S  \2 66SJuvenile justice program closure (complete section 8)                   ;2  S................................ #2 4SEffective Date:     - - -   2 S   2 S   2 S   2 S   2 S ---  2 S  S''' - @ !-   ------ 2 3 0 SECTION 2     2 3t0    2 3}0   42 30 CHILD FATALITY NOTIFICATION          2 3|0   m=------- - - ------ w2 M H=mThis serves as a preliminary notice that the child listed above died on                     ---  2 M =m - - -   2 M=m   2 M=m   2 M"=m   2 M,=m   2 M6=m ---  2 M@=m.  2 MD=m  - - - ---- - - --------- U2 c 1=mAdditional information may be requested from the            - - -   2 c=m   2 c=m   2 c=m   2 c=m   2 c=m ---  2 c=m  2 c =mCounty MDHHS    2 c+=m  2 c. =mOffice at   - - -   2 cm=m   2 cw=m   2 c=m   2 c=m   2 c=m ---  2 c=m.  2 c=m  '- @ !:-   - - -   2 n0   o--- #2  oDate of incident       2 o  - - - - - -   2  o   2 *o   2 4o   2 =o   2 Go - - -   2 Po  'o--- #2 oTime of incident       2 o  - - - - - -   2 o   2 'o   2 1o   2 :o   2 Do - - -   2 Mo  'o--- 12 oDate notified of incident         2 o  - - - - - -   2 o   2 $o   2 .o   2 7o   2 Ao - - -   2 Jo  '- @ !n- - @ !n-- @ !n- - @ !n-- @ !n-     - - -   2 0   --- @2  #Immediate notification was given to            2   72 (enter N/A if not applicable)          2   '- @ !-   - - -   2 0   ------- - - ---------  2    ---  '- - 1"-- '---  2 3  .2 7Centralized Intake on:       - - -   2    2    2    2    2  ---  2    2 via   2     '- - -- '---  2   2  In Person     2     '- - "-- '---  2 $  2 ( Telephone    2 v    '- - -- '---  2   2 Letter    2     '- - -- '---  2   2 Email   2   ''- - - ------   '- - 0!-- '---  2 2  #2 6Local MDHHS on:    - - -   2    2    2    2    2  ---  2   2 via   2     '- - -- '---  2   2  In Person     2     '- - "-- '---  2 $  2 ( Telephone    2 v    '- - -- '---  2   2 Letter    2     '- - -- '---  2   2 Email   2   ''- - - ------   '- - 0!-- '---  2 2  52 6Legal parent/guardian 1 on:        - - -   2    2     2    2    2 ' ---  2 1 \ 2 via   2     '- - -- '---  2   2  In Person     2     '- - "-- '---  2 $  2 ( Telephone    2 v    '- - -- '---  2   2 Letter    2     '- - -- '---  2   2 Email   2   ''- - - ------   '- - 0 !-- '---  2 2  52 6Legal parent/guardian 2 on:        - - -   2    2     2    2    2 ' ---  2 1 \ 2 via   2     '- -  -- '---  2   2  In Person     2     '- - " -- '---  2 $  2 ( Telephone    2 v    '- - 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