Relative Caregiver Licensing Decision

Relative Caregiver Licensing Decision

Use of form: Completion of this form is voluntary; however, its completion complies with the information to be provided to the court as required in s. 48.57(3m)(ap)(3), 48.57(3n)(ap)(3), Wisconsin Statutes or Ch. DCF 58.066 Admin. Code. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

I.Child Information
Date Form Completed
[TM1] / Name – Agency
[TM2]
Name – Child (Last, First, MI)
[TM3] / Birthdate – Child
[TM4] / Court Case Number
[TM5]
eWiSACWIS Case Number
[TM6]
II.Relative Caregiver Information
eWiSACWIS Provider Number
[TM7]
Name – Relative Caregiver 1 (Last, First, MI)
[TM8]
Name – Relative Caregiver 2 (Last, First, MI)
[TM9]
Address – (Street, City, State, Zip Code)
[TM10]
III.Licensing Decision
Choose one below.
[TM11]Denied
[TM12]Deemed unlicensable
[TM13]Refusal of foster care licensure (only applicable to providers approved for Kinship Care prior to 1/1/2010)
Explanation of licensing decision:
[TM14]
IV.Background Information as Specified in s.48.57(3m) and 48.57(3n), Wisconsin Statutes
[TM15]
V.The county department or department’s assessment of the safety of the Kinship Care relative’s or long-term Kinship Care relative’s home and the ability of the Kinship Care or long-term Kinship Care relative to care for the child.
[TM16]
VI.Agency Making the Licensing Determination
Name – Agency
[TM17]
Address – Agency
[TM18]
Name – Licensing Worker
[TM19] / SIGNATURE – Licensing Worker / Date Signed
[TM20]
Name – Licensing Worker
[TM21] / SIGNATURE – Licensing Worker / Date Signed
[TM22]
VII.Recommendation of the county department or department as to the continued placement of the child in the home of theKinship Care relative or long-term Kinship Care relative.
[TM23]
Name – Caseworker
[TM24] / SIGNATURE – Caseworker / Date Signed
[TM25]
Name – Supervisor
[TM26] / SIGNATURE – Supervisor / Date Signed
[TM27]

DCF-F-CFS2479-E (N. 02/2010)1

[TM1]This field is user entered. This field can be updated on the template.

[TM2]This field is user entered. This field can be updated on the template.

[TM3]This field is pre-filled. This field cannot be updated on the template.The data can be corrected as follows: update the Role in Document field on the Legal Documentation page.

[TM4]This field is pre-filled. This field cannot be updated on the template.The data can be corrected as follows: update the Birth Date field on the Basic tab of the child's Person Management page.

[TM5]This field is pre-filled. This field cannot be updated on the template.The data can be corrected as follows: update the Court Number field on the Legal Documentation page. The Court Number field is pre-filled from the Legal Record.

[TM6]This field is pre-filled from the eWiSACWIS Case Number. This field is system generated and cannot be updated.

[TM7]This field is pre-filled with the Provider ID for the child’s open Out of Home Placement. This field cannot be updated on the template. The data can be corrected as follows: update the open Out of Home Placement for the child.

[TM8]This field is pre-filled with the name of Parent 1 for the child’s open Out of Home Placement. This field cannot be updated on the template. The data can be corrected as follows: update the open Out of Home Placement for the childor the Members tab of the Home Provider page.

[TM9]This field is pre-filled with the name of Parent 2 for the child’s open Out of Home Placement. This field cannot be updated on the template. The data can be corrected as follows: update the open Out of Home Placement for the child or the Members tab of the Home Provider page.

[TM10]This field is pre-filled from the child's open Out of Home Placement (same as the child’s Primary address). This field cannot be updated on the template.The data can be corrected as follows: update the Provider’s address on the Create Physical Address page.

[TM11]This checkbox is user selected. This field can be updated on the template.

[TM12]This checkbox is user selected. This field can be updated on the template.

[TM13]This checkbox is user selected. This field can be updated on the template.

[TM14]This field is user entered. This field can be updated on the template.

[TM15]This field is user entered. This field can be updated on the template.

[TM16]This field is user entered. This field can be updated on the template.

[TM17]This field is user entered. This field can be updated on the template.

[TM18]This field is user entered. This field can be updated on the template.

[TM19]This field is pre-filled with the name of the licensing worker (Primary Worker) assigned to the Provider. This field can be updated on the template.

[TM20]This field is user entered. This field can be updated on the template.

[TM21]This field is user entered. This field can be updated on the template.

[TM22]This field is user entered. This field can be updated on the template.

[TM23]This field is user entered. This field can be updated on the template.

[TM24]This field is pre-filled with the name of the worker who created the template. This field can be updated on the template.

[TM25]This field is user entered. This field can be updated on the template.

[TM26]This field is pre-filled with the supervisor name documented in the Supervisor Name field on the Maintain Worker Information page for the worker who created the document. This field can be updated on the template.

[TM27]This field is user entered. This field can be updated on the template.