Date of review / Period Under Review (PUR)
Date of Current Case Opening / Date of Case Closure
Name of Local Agency / Case Manager Name and #
Supervisor Name and #
CHILDREN LIVING IN THE HOME
(additional rows can be added by pressing “tab” in last column/row)
First & Last Name / Date of Birth/Age / Gender
CASE MANAGER INFORMATION
In the blanks below, please provide the information about your work experience and caseload.
How long have you been an in-home worker? / Years / Months
How many cases do you have where you are assigned as the primary worker? / Foster Care / In-Home / Other / Total
How long have you been assigned to the case being reviewed? / Years / Months
What challenges have you experienced in working this case?
Expand box if necessary.
What do you think has gone well in working this case?
Expand box if necessary.
Key Case Participants for Case:
Please refer to OCR Procedures Manual for definitions
Role / Interview?
Y/N / Comments
Father
Mother
What is the reason for the agency’s involvement? Check all that apply
Physical abuse
Sexual abuse
Emotional maltreatment
Neglect (not including
medical neglect)
Medical neglect / Abandonment
Mental/physical health of parent
Mental/physical health of child
Substance abuse by parent(s)
Child’s behavior / Substance abuse by child
Domestic violence in the child’s
home
Child in juvenile justice system
Other (specify)
CPS REPORTS TABLE – list those received during the PUR. If a 960 report received a ‘services required’ finding during the PUR, please also include all reports received within the six months prior to the PUR.
(additional rows can be added by pressing “tab” in last column/row)
Report Date / First Name of Child / Allegation / Priority Level / Date Assigned for an Assessment / Date Assessment Initiated / Date of
Face-to-face Contact with Child / Relationship of Alleged Perpetrator to Child / Disposition
CASE NARRATIVE
Expand boxes if necessary.
Brief summary of family’s involvement with agency since case opening.
Please identify and include the involvement of the mother(s) and father(s) as applicable to the case.
Include where and with whom the children are living.
How did agency assess safety and risk concerns for the family during PUR?
Please note safety and risk concerns identified by agency, if applicable.
Briefly summarize how the agency utilized safety plans during the PUR.
Please list any services for the child and/or family identified by your agency that were needed but not provided/not available.
Briefly describe how the agency involved the child(ren), mother(s) and father(s) in case planning during the PUR.
If educational needs of one or more of the children were a reason for agency involvement, briefly describe the agency’s involvement in meeting the child(ren)’s educational needs.
Please summarize any court involvement during the PUR, if applicable.
Education informationduring the PUR
Please note if agency was involved in addressing any of the children’s educational needs during the PUR. If so, please briefly describe agency efforts.
Physical & Dental Health informationduring the PUR
Please note if agency was involved in addressing any of the children’s physical or dental health (including vision) needs during the PUR. If so, please briefly describe agency efforts.
Behavioral/Mental Health Information
Please note if agency was involved in addressing any of the children’s behavioral or mental health needs during the PUR. If so, please briefly describe agency efforts.
GENOGRAM
Please include a genogram for the family. It can be scanned into this document, or if helpful, instructions for completing a genogram can be found on the ND OCR Genogram Resource.
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