Child Protective Services Case Summary and Classification Decision of Child Abuse/Neglect Referral
A.
Case Name: / Referral Date: / Assignment Date: /Street Address:
City/State/Zip
B. / Classification / Alleged Perpetrator’s Names / Severe Abuse
Children’s Names / Specific Allegations for Each Child / Yes / No
1.
2.
3.
4.
5.
6.
Classification Decision Codes: (Completion of page 2 required) See Attachment
AUPU: Allegation Unsubstantiated and Perpetrator Unsubstantiated / UABC: Unable to Complete
ASPS: Allegation Substantiated and Perpetrator Substantiated / SREQ: Services Required
ASPU: Allegation Substantiated and Perpetrator Unsubstantiated / SREC: Services Recommended
ASPK: Allegation Substantiated and Perpetrator Unknown / NSREQ: No Services Required
CSBP: Allegation Unsubstantiated/Child with Sexual Behavior Problems
C. Disposition Decision: (Explain)
Continue DCS Services:
Refer for Other Services and Close:
Assessed and Closed:
D
Case Manager’s Signature / Date / Supervisor’s Signature / Date
E. / Case Name:
Instructions: / Condense the finding rationale for each allegation relative to the child victim(s). Be sure to identify the facts that provided a basis for the classification decision.
Summarize the key points and dates of the child or children’s statements and/or the observation of the child or children’s physical state or home environment:
Summarize professional, medical or psychological findings or opinions: What is the witness’s or the collateral’s oral or written finding/opinion of the incident(s)/allegation(s)?
Summarize alleged perpetrator’s statement or admission: What is the perpetrator’s explanation of the incident(s)/allegation(s)?
Summarize witnesses’ descriptions of what they saw and what they believe substantiates child abuse/neglect:
Summarize any other evidence or factors that support the investigative finding(s) for the allegation(s) of abuse/neglect:
Check the “Forms” Webpage for the current version and disregard previous versions. This form may not be altered without prior approval.
Distribution: Copies: Juvenile Court in All Cases
District Attorney in Severe Child Abuse Cases
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CS-0740 Revised 4/17 RDA 2993