BROWARD COUNTY SHERIFF’S OFFICE

Child Protective Investigations Section

359 North State Road 7

Plantation, FL 33317

(954) 797-5299

CASE OPENING DOCUMENT / ESI STAFFING FORM

Last Name of Children:
Abuse Report No.:
/ Date Submitted:
Child Protective Investigator:
/ Cell Phone:
/ Office:
/ Pager:
Supervisor’s Name:
/ Cell Phone:
/ Office:
/ Pager:
Choose One:
ChildNet Staffing for Early Service Intervention
New Dependency Case
Existing Dependency Case: Judicial Case No: CJ-DP
Add-on of additional sibling to : Judicial Case No: CJ-DP
Choose One:
Shelter VPS Referral for Services Consultation
Straight Petition for Adjudication Re-Open Sua Sponte
Other (Question #3 must be answered):
Yes No - This case appears appropriate for referral to Dependency Drug Court.
Yes No - This case has children or parents who may be subject to Indian Child Welfare Act
Yes No - Does case involve person(s) needing communication assistance?
Check all applicable: Deaf or hard of hearing ; Visually impaired ; Limited English Proficiency
Name: Child ; Mother ; Father ; Caregiver/Other
Documents:
Check all that exist. Provide these documents initially to the OAG if filing and as they become available through the ongoing Investigation.
Number of Abuse Reports: (Copies of all current and prior reports must be attached. Submitted by statute to the court at the shelter hearing)
Type / Date / Type / Date
Medical Records/Reports / SATC/CPT Reports
Risk Assessment / Additional Witness List
Current/Prior Case Plans / Juvenile Delinquency History
LEO/Police Report(s) / Chronological Notes
Child(ren) Photographs / Home Photographs
Copy of the file for discovery provided to Shelter Attorney/Name:
Other:
A check of DocketTrac, Quest and/or Clerk of Courts found the following:
Choose One:
There are no related cases.
The following are the related cases (add additional pages if necessary) Please attach documentation.
Related Case No. 1
Case Name(s)
Petitioner:
Respondent:
Case No.: / Division:
Type of Proceeding: (Check all that apply)
Dissolution of Marriage Mental Health
Custody Paternity
Child Support Adoption
Juvenile Dependency Modification/Enforcement/Contempt Proceedings
Termination of Parental Rights Juvenile Delinquency
Domestic/Sexual/Daring/Repeat Criminal
Violence Injunctions Other (specify) ______
State where case was decided or is pending:
Florida Other (specify) ______
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida)
Title of Last Court Order / Judgment (if any)
Date of Court Order/Judgment (if any)
Relationship of Cases (Check all that apply)
pending case involves same parties, children, or issues; may affect court’s jurisdiction;
order in related case may conflict with an order in this case; order in this case may conflict with previous order in related case
Statement as to the relationship of the cases:
Related Case No. 2
Case Name(s)
Petitioner:
Respondent:
Case No.: / Division:
Type of Proceeding: (Check all that apply)
Dissolution of Marriage Mental Health
Custody Paternity
Child Support Adoption
Juvenile Dependency Modification/Enforcement/Contempt Proceedings
Termination of Parental Rights Juvenile Delinquency
Domestic/Sexual/Daring/Repeat Criminal
Violence Injunctions Other (specify) ______
State where case was decided or is pending:
Florida Other (specify) ______
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida)
Title of Last Court Order / Judgment (if any)
Date of Court Order/Judgment (if any)
Relationship of Cases (Check all that apply)
pending case involves same parties, children, or issues; may affect court’s jurisdiction;
order in related case may conflict with an order in this case; order in this case may conflict with previous order in related case
Statement as to the relationship of the cases:
Related Case No. 3
Case Name(s)
Petitioner:
Respondent:
Case No.: / Division:
Type of Proceeding: (Check all that apply)
Dissolution of Marriage Mental Health
Custody Paternity
Child Support Adoption
Juvenile Dependency Modification/Enforcement/Contempt Proceedings
Termination of Parental Rights Juvenile Delinquency
Domestic/Sexual/Daring/Repeat Criminal
Violence Injunctions Other (specify) ______
State where case was decided or is pending:
Florida Other (specify) ______
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida)
Title of Last Court Order / Judgment (if any)
Date of Court Order/Judgment (if any)
Relationship of Cases (Check all that apply)
pending case involves same parties, children, or issues; may affect court’s jurisdiction;
order in related case may conflict with an order in this case; order in this case may conflict with previous order in related case
Statement as to the relationship of the cases:
Related Case No. 4
Case Name(s)
Petitioner:
Respondent:
Case No.: / Division:
Type of Proceeding: (Check all that apply)
Dissolution of Marriage Mental Health
Custody Paternity
Child Support Adoption
Juvenile Dependency Modification/Enforcement/Contempt Proceedings
Termination of Parental Rights Juvenile Delinquency
Domestic/Sexual/Daring/Repeat Criminal
Violence Injunctions Other (specify) ______
State where case was decided or is pending:
Florida Other (specify) ______
Name of Court where case was decided or is pending (for example, Fifth Circuit Court, Marion County, Florida)
Title of Last Court Order / Judgment (if any)
Date of Court Order/Judgment (if any)
Relationship of Cases (Check all that apply)
pending case involves same parties, children, or issues; may affect court’s jurisdiction;
order in related case may conflict with an order in this case; order in this case may conflict with previous order in related case
Statement as to the relationship of the cases:
Choose One:
I do not request coordination of litigation in any of the cases listed above.
I do request coordination of the following cases:
Check all that apply:
Assignment to one judge
Coordination of existing cases will conserve judicial resources and promote an efficient determination of these cases
because:
CHILDREN’S INFORMATION
Children’s Information (Required by Law); All children in the home must be listed
Legal Name / Race / Sex / DOB / SSN / Place of Birth / Was mother married at the time of conception?
If yes, to whom/ Date of Marriage / Father / Mother
Residence of Child (ren) for the past five years (Required by Law)
Address: / From / To / Adult(s) with whom child(ren) resided:
PARENT’S INFORMATION
MOTHER
Mother’s Legal Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was mother notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
What information did she provide?
FATHER: Pick one: Married Birth (per Birth Certificate / Attach) Alleged
Father’s Legal Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was father notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
FATHER Pick one: Married Birth (per Birth Certificate / Attach) Alleged
Father’s Legal Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was father notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
FATHER Pick one: Married Birth (per Birth Certificate / Attach) Alleged
Father’s Legal Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was father notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
FATHER Pick one: Married Birth (per Birth Certificate / Attach) Alleged
Father’s Legal Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was father notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
FATHER Pick one: Married Birth (per Birth Certificate / Attach) Alleged
Father’s Legal Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was father notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
LEGAL GUARDIAN/CUSTODIAN INFORMATION
Legal Guardian/Custodian Name:
/ Date of Birth:
/ SSN#:
/ Home Phone:
/ Cell Phone:
Address:
If, location unknown has diligent search begun? No Yes, Date:
If location unknown, Inquiry was made of the following person(s) to locate to date:
Criminal History: No Yes, If yes explain:
Inmate Number (if applicable):
/ If incarcerated, where?
/ Need to be ordered from facility:
No Yes
Was father notified about shelter hearing?
No Yes / How?
By Phone In Person Other:
Does legal guardian/custodian know the identity and whereabouts of the parents? No Yes
What information did he/she provide?
Basis for Guardianship: Kinship Court Order Private Agreement Other:

* Court Order granting custody or guardianship should be obtained and attached

ALLEGED PERPETRATOR INFORMATION
PERPETRATOR
Perpetrator Name:
/ Relationship to child(ren):
Was Perpetrator arrested?
No Yes, If yes answer the following: / Inmate#:
/ If incarcerated where? (facility)
Charges:
Law Enforcement (LE) Agency:
/ District:
/ Agency Case#:
/ LE Name / ID#:
/ LE Phone #:
LE Offense Report Attached? Yes No, If not, why?
PERPETRATOR
Perpetrator Name:
/ Relationship to child(ren):
Was Perpetrator arrested?
No Yes, If yes answer the following: / Inmate#:
/ If incarcerated where? (facility)
Charges:
Law Enforcement (LE) Agency:
/ District:
/ Agency Case#:
/ LE Name / ID#:
/ LE Phone #:
LE Offense Report Attached? Yes No, If not, why?
VICTIM CHILD INFORMATION
VICTIM CHILD
Victim Child Name:
/ # of Photos:
/ Type of Photos:
/ Taken By:
Date Photos Taken:
/ Description of Content:
Medical Exams? No Yes, If yes, by whom?
CPT SATC Hospital Private / Date:
/ Where:
Examiner’s Name:
/ Title:
/ Phone #:
Diagnosis / Impressions:
Description of Injury:
Does Examiner feel condition is due to abuse / neglect?
No Yes / Type:
Does Examiner or their agency have recommendations as to placement: No Yes, If yes, with whom:
Protective Investigators recommendation as to placement:
VICTIM CHILD
Victim Child Name:
/ # of Photos:
/ Type of Photos:
/ Taken By:
Date Photos Taken:
/ Description of Content:
Medical Exams? No Yes, If yes, by whom?
CPT SATC Hospital Private / Date:
/ Where:
Examiner’s Name:
/ Title:
/ Phone #:
Diagnosis / Impressions:
Description of Injury:
Does Examiner feel condition is due to abuse / neglect?
No Yes / Type:
Does Examiner or their agency have recommendations as to placement: No Yes, If yes, with whom:
Protective Investigators recommendation as to placement:
VICTIM CHILD
Victim Child Name:
/ # of Photos:
/ Type of Photos:
/ Taken By:
Date Photos Taken:
/ Description of Content:
Medical Exams? No Yes, If yes, by whom?
CPT SATC Hospital Private / Date:
/ Where:
Examiner’s Name:
/ Title:
/ Phone #:
Diagnosis / Impressions:
Description of Injury:
Does Examiner feel condition is due to abuse / neglect?
No Yes / Type:
Does Examiner or their agency have recommendations as to placement: No Yes, If yes, with whom:
Protective Investigators recommendation as to placement:
MALTREATMENT FINDINGS
Complete the following section thoroughly for the OAG to properly prepare your petition. You must state all the supportive evidence and corresponding findings of maltreatment to be included within your petition.
Include all of the allegations in the Abuse Report and respective findings: verified, some indicators or no indicators.
Include additional risk factors you have discovered in your investigation. Do Not Say, “See Abuse Report” - You must be as specific as possible and provide all supporting documentation or sources of information that would assist in the preparation of this document.
The child(ren) have been abused, neglected or abandoned, describe:
The child(ren is/are at imminent reisk of abuse / harm [On emergency removal describe]:
Choose All That Apply:
The continuation in the home is contrary to the welfare of the children because the home situation presents a substantial and immediate danger which cannot be mitigated by provision of preventive services and placement is needed to protect the children specifically
The children are abused/neglected/or abandoned or is/are suffering from or in imminent danger of injury or illness as a result of abuse, neglect, or abandonment, specifically:
The children are dependent children by previous order of the court and the custodian has materially violated a condition of placement imposed by the court, specifically:
The children has/have no parent, legal custodian, or suitable, responsible adult relative immediately known and available to provide supervision and care, specifically:

* Please provide additional information on a separate sheet if necessary.

CHILD SAFETY ASSESSMENT
Initial Safety Assessment completed: / Date: / Time:
Safety Assessment to include abuse, neglect, harm findings and severity both present and past; all other risk factors; vulnerabilities; parents/custodian’s ability to protect, cooperate, address issues.