Revised 4-10
ICPC Supervision Report
90 Day
Date of Report: mm/dd/yy
Name of Child (ren): [Enter name of child(ren)
Name of Caretaker(s): [Enter name of caretaker(s)]
Address of Placement: [Enter full address of placement]
Courtesy Caseworker: [Enter name of Caseworker] Phone Number: [Enter phone # of Caseworker]
(Receiving State)
Reporting Period: [Enter beginning date of report and ending date]
Dates and Locations of Face-to-Face Contact: [Enter mm/dd/yy and locations of all face-to-face contacts]
Briefly discuss child(ren)’s current circumstances, addressing child(ren)’s safety in current placement and child(ren)’s well-being: [Use clear concise language and be certain to include information on the safety and well-being of the child]
Child(ren)’s school performance, if applicable: (Attach copies of report card, IEP, evaluations, if applicable) [Enter school performance background information]
Child(ren)’s health & medical status, including date of medical and dental appointments and names of service providers, if applicable: (Attach records, evaluations, therapy reports, if applicable) [Enter health and medical background information]
Assessment of current placement and caretakers, e.g., (physical condition of the home, caretaker’s commitment to child, current status of caretaker family, any changes in family composition, health, financial situation, work, legal involvement, social relationships, child care arrangements): [Enter background information of current placement and caretakers]
Permanent plan status: What progress has been made toward a permanent goal? Has the goal changed? Are there any recommendations? [Enter background information of the child's permanency plan]
List any unmet needs, and recommendations to meet those needs: (Sending State is responsible for case planning and for funding) [Enter any unmet needs and how those needs will be addressed]
Recommendation:
Continue Placement
Continue Supervision
Terminate Supervision
Receiving State Concurs With:
Continue with current permanency goal
Return custody to parent, terminate jurisdiction
Establish guardianship
Finalize adoption
Other [Specify any other permanency issues]
ICPC Supervision Form – 90 Day Report
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Revised 4-10
OFFICIAL INTERSTATE COMPACT OFFICE USE ONLY:
The Receiving State Compact Administrator/Deputy Compact Administrator/ICPC Specialist concurs with this recommendation.
The Receiving State Compact Administrator/Deputy Compact Administrator/ICPC Specialist does not concur with this recommendation.
[Print name of Compact Administrator] [mm/dd/yy]
Name Date
ICPC Supervision Form – 90 Day Report
Page 2 of 2