Department of Family and Children S Services

Santa Clara County

Social Services Agency

Department of Family and Children’s Services

Gomez Grievance Hearing

Preliminary Review Worksheet

Case Name / Case Number / CWS/CMS Referral Number
Investigating Social Worker / Telephone Number / Investigating Social Worker’s Supervisor
Name of Person Requesting Hearing / Person’s Telephone Number
Court Hearing? None Indicated in Record or CWS/CMS
Yes Juvenile Court Pending / Hearing Concluded
Date / Date
Yes Adult Court Pending / Hearing Concluded
Date / Date
DA Tracking: No Records / Docket Number:
Notes:
Allegation: Sexual Abuse Physical Abuse Severe Neglect Emotional Abuse
Active:
Investigation? Disposition: Inconclusive Substantiated Unfounded
* Victim(s) interviewed? Yes No
*Suspect interviewed? Yes No
*Caregiver/Parent) interviewed? Yes No
Other children in home interviewed? Yes No
Witness(es) interviewed? Yes No
Other evidence considered in investigation: Extended Family Member Interviewed Previous Referral reviewed Suspect’s criminal record reviewed Collaterals interviewed* Collateral’s reports reviewed*
Social Worker for sibling(s) or half sibling(s) in open case interviewed Siblings’ or half siblings open case file reviewed** closed case file(s) reviewed**

* For example, medical staff, counseling, educational, law enforcement, probation, and parole staff

** Including social worker court reports

Preliminary Review Findings:
Active investigation completed. Proceed to Grievance Hearing.
Active investigation not completed. Refer to SSPM.
Juvenile Court petition sustained. No right to Grievance Hearing.
Criminal court pending. No right to Grievance Hearing until matter is dismissed or determined to be
unfounded.
Other :
If referred for SSPM review, decisions made and actions taken:
Active investigation completed. Proceeded with Grievance Hearing.
Active investigation not completed. Refer to Administrative Staffing.
Administrative Staffing Results / Date of Staffing:
Active investigation completed.
Active investigation not completed.
Remove from CACI listing.
Modify disposition from / to
Re-open referral to complete investigation.
G:\template\forms\SCZ 45.doc
File: 1st Fastener, Left - Under / Gomez Grievance Hearing Preliminary Review – 2-1-11
Routing: SW III -> SWS->Admin. Sup SSPM->ER SW’s SSPM->SW III / Page 1 of 2