ࡱ> q bjbjbb e,efef3e^ ^ $Pd(dP f f f !"#HL'N'N'N'N'N'N'$A*,r'd#!!d#d#r'f f HG($$$d#Rf f L'$d#L'$$%4&f @Zb#R&8'](0(&,/$/4&/4&d#d#$d#d#d#d#d#r'r'$d#d#d#(d#d#d#d#/d#d#d#d#d#d#d#d#d#^ X : Foster Care/Adoption/Juvenile Justice Caseworker/Child Visit ToolMichigan Department of Health and Human Services1. Child/Children s name(s)2. Date/time of visit FORMTEXT       FORMTEXT      3. Caseworker name4. County name/number FORMTEXT       FORMTEXT      5. Visit location6. Announced visit FORMCHECKBOX  Child s residence FORMCHECKBOX  Other FORMTEXT       FORMCHECKBOX  Yes FORMCHECKBOX  No7. List all persons/caregiver(s) present at visit FORMTEXT      8. List any changes in the home, including who resides in home FORMTEXT      9. Assessment of home (any sanitary concerns, safety or privacy issues, safe sleep issues for infants) FORMTEXT      10. Notice of court hearing given FORMCHECKBOX  Caregiver FORMCHECKBOX  ChildCHILD VISIT11. Child seen alone during visit?12. Viewed childs bedroom? FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Yes FORMCHECKBOX  No13. Note childs physical appearance FORMTEXT      14. Child s feelings/observations about being in their residence FORMTEXT      15. Education  grades, Individualized Education Plan (IEP), Early On, school issues FORMTEXT      16. Discuss parent/sibling visitation plan FORMTEXT      17. Extracurricular/cultural/hobbies  participated in since last visit FORMTEXT      18. Medical/dental/mental health needs and appointments FORMTEXT      19. Discuss psychotropic medications with child and document side effects, benefits, administration, time frame, and regularity FORMTEXT       20. Permanency plan and how shared with the child FORMTEXT      CAREGIVER VISIT21. Date of child s last physical exam22. Date of child s last dental exam FORMTEXT       FORMTEXT      23. List medications  dosage, physician, diagnosis of child FORMTEXT      24. Discuss psychotropic medications with caregiver and document side effects, benefits, administration, time frame, and regularity FORMTEXT      25. Child s medical/dental/mental health  concerns, appointments, medication reviews, lab work, psychological evaluations, monitoring treatment, follow-up care, and therapy updates FORMTEXT      26. Progress toward reaching goals addressed in the Service Plan/Risk Assessment FORMTEXT      27. Child behaviors  worker/caregiver concerns, developmental milestones FORMTEXT      28. Human trafficking indicators FORMTEXT      29. Education  school status/performance, behaviors, and services provided FORMTEXT      30. Caregiver tasks required to meet the child s needs (completed/attempted) FORMTEXT      31. Caregiver family adjustment to child s placement FORMTEXT      32. Permanency plan and how shared with the caregiver FORMTEXT      33. Any CPS complaint made since last visit FORMTEXT      34. For relative placement, if the relative is pursuing foster care licensure, obtain update on progress towards achieving a license FORMTEXT       CHILD MOVE/REPLACEMENT (if applicable)35. Medicaid card/number/records sent to caregiver within 5 days FORMTEXT      36. Enrolled in/attending school and provided education records within 5 days FORMTEXT      37. If child is attending same school, discuss transportation plan FORMTEXT      38. Revision of parent/sibling visitation (if applicable) FORMTEXT      OTHER39. Unmet needs or services to be provided FORMTEXT      40. Follow-up activities for worker FORMTEXT      41. Date of next scheduled visit FORMTEXT      42. List changes in dosage or discontinuation of psychotropic medications FORMTEXT      The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. FOSTER CARE/ADOPTION/JUVENILE JUSTICE CASEWORKER/ CHILD VISIT TOOL (DHS-904A) INSTRUCTIONSThis document provides line-by-line instructions for the Foster Care/Adoption/Juvenile Justice Caseworker Visit Tool. All information gathered at the visit must be documented in the Initial Services Plan (ISP)/Updated Services Plan (USP). Item #Item NameInstructions1.Child/Childrens name(s).List the names of all the children.2.Date/time of visit.Document date and time the visit took place.3.Caseworker name.Document the name of the caseworker who completed the visit.4.County name/number.Document county name and county number.5.Visit location: Childs residence or other.Check the box Childs residence if the visit took place where the child is currently living. If the visit was not in the childs residence check the Other box and document where the visit took place, i.e. school.6.Announced visit.Document if this was an announced visit by checking the appropriate box.7.List all person/caregiver(s) present at the visit.List the name of each person present at the visit and note their relationship to child.8.List any changes in the home, including who resides in the home.Document all changes in the home/residence of the child including who is residing in the home at the time of the visit and if the placement is stable.9.Assessment of home.Document all concerns of the home (include sanitary, safety or privacy issues and safe sleep issues for infants).10.Notice of court hearing given.Document if the caregiver and the child (if developmentally appropriate) were given notice of the next court hearing.CHILD VISIT11.Child seen alone during visit?Check the appropriate box to indicate if the child was seen alone or not. The caseworker should see the child alone for part of the visit if the child is older than an infant.12.Viewed childs bedroom?Check the appropriate box to indicate if the caseworker viewed the childs bedroom.13.Note childs physical appearance.Document childs physical appearance and note any change.14.Childs feelings/observations about being in their residence.Document the childs feelings and observations about living in their residence including relationships with others living there. 15.Education grades, Individualized Education Plan (IEP), Early On, school issues.Identify the childs educational needs and if those needs are appropriately addressed or note the plan to address the needs. Document information pertinent to the childs education including grades, IEP, Early On, school achievements or issues.16.Discuss parent/sibling visitation plan.Document information pertinent to the visitation between parents and siblings.17.Extracurricular/cultural/ hobbies participated in since last visit.Update information on extracurricular/cultural/hobbies the child participated in since last visit including activities child is involved in to maintain connections with their neighborhood, community, faith, extended family, tribe, school, and friends.18.Medical/dental/mental health needs and appointments.Identify medical, dental (age appropriate), mental health and behavioral health needs, appointments. Document if the needs are appropriately addressed or note the plan to address the needs.19.Discuss psychotropic medications with child and document.Documentation and discussion should include side effects and benefits of medication, administration of medication, time frame, and regularity. Concerns about health or daily function should also be documented.20.Permanency plan and how shared with the child.Document the permanency plan and note how the caseworker shared the plan with the child/children (if developmentally appropriate).CAREGIVER VISIT21.Date of childs last physical exam.Document date of the last physical exam for each child.22.Date of childs last dental exam.Document date of the last dental exam for each child.23.List medications - dosage, physician, diagnosis for the child.Document the medication name, dosage, physician prescribing the medication including the diagnosis and purpose for the medication for the child.24.Discuss psychotropic medications with caregiver and document.Discuss and document benefits, side effects, complications or concerns, compliance with appointments, and dates or last/upcoming appointments. Conversation should also include any barriers to medication availability, administration, and refill process.25.Childs medical/dental/mental health-concerns, appointments, medication reviews, lab work, psychological evaluations, monitoring, treatment, follow-up care and therapy updates.Document medical, dental, mental health concerns, appointments, medication reviews, lab work, psychological evaluations, monitoring, and treatment including therapy updates. Document if the needs are appropriately addressed or note the plan to address the needs.26.Progress toward reaching goals addressed in the Service Plan/Risk Assessment.Document progress or lack of progress that the family has made in achieving the Service Plan goals and Risk Assessment. 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Withdrawal or lack of interest in previous activities. Signs of current physical abuse and/or sexually transmitted diseases. Inexplicable appearance of expensive gifts, clothing, cell phones, tattoos, or other costly items. Presence of an older boyfriend or girlfriend. Drug addiction. Gang involvement. The presence of some of these indictors is not conclusive evidence of trafficking, but further inquiry should take place. When two or more indicators are checked or if you have reasonable cause to suspect trafficking or any form of abuse or neglect, contact Centralized Intake at 855-444-3911.29.Education school status/performance, behaviors, and services provided.Identify childs educational needs and document if those needs are addressed through appropriate services or document the plan to address the needs. Document information pertinent to the childs education including grades, IEP, Early On, school achievements, issues, behavior and school services provided to the child.30.Caregiver tasks required to meet the childs needs (completed/attempted).Document caregiver tasks that are needed to meet the childs needs.31.Caregiver family adjustment to childs placement.Document information regarding how the child is adjusting to this placement, including information on relationships with others residing in the placement. 32.Permanency plan and how shared with the caregiver.Document the permanency plan and if the caseworker shared the plan with the parents/caregiver.33.Any CPS complaint made since last visit.Document information regarding any Child Protective Services complaints that occurred since the caseworkers last visit.34.For relative placement, if the relative is pursuing foster care licensure, obtain update on progress towards achieving a license.Document if the relative is pursuing foster care licensure and give an update on their progress towards achieving a license.CHILD MOVE/REPLACEMENT (if applicable)35.Medicaid card/number sent to caregiver within 5 days.Note if the Medicaid card/number was sent to the caregiver within 5 days and if the caregiver received the card/number.36.Enrolled in/attending school within 5 days.Document if the child was enrolled in and attending school within 5 days of placement. If not give the reason and note the plan for enrollment.37.If child is attending the same school, discuss transportation plan.Document the name of the school the child is attending and if it is the same school the child attended prior to placement, explain the transportation plan.38.Revision of parent/sibling visitation (if applicable).Document the revised parent/sibling visitation plan that was developed due to the child being moved to a new placement.OTHER39.Unmet needs or services to be provided.Document all unmet needs and services to be provided to the family to ensure the safety and well-being of the child/children.40.Follow-up activities for worker.List activities for the worker to address or follow up on to provide support services.41.Date of next scheduled visit.List activities for the worker to address or follow up on to provide support services.42.Contact FC-PMOUIf any psychotropic medications have a change in dosage or are discontinued, document and email this information to the FC-PMOU mailbox. Note: Medications cannot be discontinued unless recommended by a prescribing physician. If the caregiver and/or child report wishing to discontinue a medication, suggest making an appointment with the prescribing clinician to discuss.     DHS-904-A (Rev. 1-20) Previous edition obsolete.  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Human Services (MDHHS)TMDHHS;DHS-904-A;Foster Care;Adoption;Juvenile Justice;Caseworker;Child Visit;Tool82b620904-A.dotxSimmons, Scott (DTMB)1Microsoft Office Word@G@Di1@BLb@(b+GXcVT$m 1    0."System- "SystemL%s` &0-"System--@Times New Roman---  2 0    0''@"Arial--- 2 0 DHS   2 @0 - 2 E0 904   2 `0 - 2 e0 A (Rev.    2 0 1   2 0 - 2 0 20   2 0 )  2 0   22 0 Previous edition obsolete.          2 0    2 0 1   2 0    0''2@"Arial--- m2 .(A2FOSTER CARE/ADOPTION/JUVENILE JUSTICE CASEWORKER/CHILD VISIT TOOL                      2 .2  '  J2@"Arial--- S2 B02JMichigan Department of Health and Human Services               2 Ba2J  '  ]UK--- 42 Z"KU]1. Child/Childrens name(s)         2 ZKU]  ']KV--- +2 ZZVK]2. Date/time of visit       2 ZVK]  '- @ !J-- @ !J- - @ !J-- @ !6J- - @ !JT-- @ !JU- - @ !J-- @ !J- - @ !K- - @ !KT- - @ !K- U]@1Courier New---  2 m"]U   2 m,]U   2 m6]U   2 m?]U   2 mI]U   2 mR]U  ']V---  2 mZV]   2 mdV]   2 mnV]   2 mwV]   2 mV]   2 mV]  '- @ !(]- - @ !(]T- - @ !(]- --- &2 "3. Caseworker name       2   '--- +2 4. County name/number      2 K  '- @ !-- @ !z- - @ !-- @ !- - @ !T-- @ !U- - @ !- - @ !- - @ !- - @ !- ---  2 "   2 ,   2 6   2 ?   2 I   2 R  '---  2    2    2    2    2    2   '- @ !- - @ !- - @ !- U--- %2 "U5. Visit location       2 U  'V--- &2 ZV6. Announced visit     2 V  '- @ !-- @ !z- - @ !-- @ !- - @ !T-- @ !U- - @ !- - @ !- - @ !T- - @ !- ---   '-- 2#-- '---  2 4  %2 8Childs residence       2   '%--- % % '-- -- '---  2 %  2 %Other    2 %  'U%---  2 *%U   2 4%U   2 >%U   2 G%U   2 Q%U   2 Z%U  'V--- V V '-- j[-- '---  2 lV  2 pVYes   2 V  '---   '-- -- '---  2   2 No   2   '- @ !-   - @ !T-  - @ !- --- U2 "17. List all persons/caregiver(s) present at visit              2 d  '- @ !-- @ !- - @ !-- @ !J- - @ !%-- @ !.&- - @ !T-- @ !AU- - @ !-- @ !{- - @ !- - @ !- - @ !-  ---  2 "    2 ,    2 6    2 ?    2 I    2 R   '- @ !(- - @ !(- !--- h2 ">!8. List any changes in the home, including who resides in home                 2 !  '- @ ! -- @ ! - - @ ! - - @ !- - @ !- I!---  2 0"!I   2 0,!I   2 06!I   2 0?!I   2 0I!I   2 0R!I  '- @ !(!- - @ !(!- \J--- A2 Y"$J\9. Assessment of home (any sanitary          n2 Y.BJ\concerns, safety or privacy issues, safe sleep issues for infants)                  2 YJ\  '- @ !I-- @ !I- - @ !I- - @ !J- - @ !J- \---  2 l"\   2 l,\   2 l6\   2 l?\   2 lI\   2 lR\  '- @ !(\- - @ !(\- --- =2 "!10. Notice of court hearing given           2    '- @ !-- @ !- - @ !- - @ !- - @ !- ---   '-- 2#-- '---  2 4  2 8 Caregiver     2 ~  '---   '-- -- '---  2   2 Child    2   '- @ !-  - @ !- @"Arial--- 2  CHILD VISIT       2 |  '- @ !-- @ !- - @ !-- @ !k- - @ !-- @ !- - @ !-   --- >2 ""11. Child seen alone during visit?           2   '--- 42 12. Viewed childs bedroom?         2 k  '- @ !-- @ !- - @ !-- @ !y- - @ !-- @ !z- - @ !-- @ !- - @ !- - @ !- - @ !- ^--- ^ ^ '- - 2#--  '---  2 4^  2 8^Yes   2 T^  '^--- ^ ^ '- - sd--  '---  2 u^  2 y^No   2 ^  '---   '- - --  '---  2   2 Yes   2   '---   '- - --  '---  2   2 No   2    '- @ !-  - @ !-  - @ !- --- 2 "13.   2 8  ;2 = Note childs physical appearance           2 *  '- @ !-- @ !A- - @ !^-- @ !8_- - @ !-- @ !A- - @ !-- @ !8- - @ !- - @ !- - @ !- ---  2 "   2 ,   2 6   2 ?   2 I   2 R  '- @ !- - @ !- "--- k2 "@"14. Childs feelings/observations about being in their residence                   2 "  '- @ !-- @ !- - @ !- - @ !- - @ !- \"---  2 2""\   2 2,"\   2 26"\   2 2?"\   2 2I"\   2 2R"\  '- @ !:"- - @ !:"- o]---  2 l"]o15. Education      2 l]o   2 l]o  2 l]ogrades,   e2 l<]oIndividualized Education Plan (IEP), Early On, school issues               2 l|]o  '- @ !\-- @ !\- - @ !\- - @ !]- - @ !]- o---  2 "o   2 ,o   2 6o   2 ?o   2 Io   2 Ro  '- @ !:o- - @ !:o- --- J2 "*16. Discuss parent/sibling visitation plan             2 A  '- @ !-- @ !- - @ !- - @ !- - @ !- ---  2 "   2 ,   2 6   2 ?   2 I   2 R  '- @ !9- - @ !9-  --- C2 "% 17. Extracurricular/cultural/hobbies            2     2 '   ;2 *  participated in since last visit         2    '- @ !-- @ !- - @ !- - @ !- - @ !- B ---  2 " B   2 , B   2 6 B   2 ? B   2 I B   2 R B  '- @ !9 - - @ !9 - UC--- 2 R"CU18.  X2 R=3CUMedical/dental/mental health needs and appointments               2 RCU  '- @ !B-- @ !B- - @ !B- - @ !C- - @ !C- U---  2 e"U   2 e,U   2 e6U   2 e?U   2 eIU   2 eRU  '- @ !:U- - @ !:U- --- 2 "j19. Discuss psychotropic medications with child and document side effects, benefits, administration, time                           %2 "frame, and regula     2 rity  2   '- @ !-- @ !- - @ !- - @ !%- - @ !%- ---  2 "   2 ,   2 6   2 ?   2 I   2 R  ---  2 $    2 $   2   '''- @ !9- - @ !-- @ !-- @ !- - @ !9- - @ !-- @ !-  "SystemL%s` &0- -   00//..K ՜.+,D՜.+,X hp  :4Michigan Department of Health and Human Services]p3 BFoster Care/Adoption/Juvenile Justice Caseworker/Child Visit Tool Title `Dt   8MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_Enabled7MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_SiteId6MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_Owner8MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_SetDate5MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_Name<MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_Application9MSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_ActionId EMSIP_Label_2f46dfe0-534f-4c95-815c-5b1af86b9823_Extended_MSFT_Method SensitivityTrue(d5fb7087-3777-42ad-966a-892ef47225d1SimmonsS4@michigan.gov 2020-01-22T20:27:12.6303065Z(Public Data (Published to the Public)(Microsoft Azure Information Protection(0bd2f42b-ce5d-4bef-b129-e77d5c3dfc48Manual(Public Data (Published to the Public)  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~     Root Entry F ]bData W1Table/WordDocumente,SummaryInformation((fDocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q