Screening for Child's Status As Indian, CFS-2322

SCREENING FOR CHILD'S STATUS AS INDIAN

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

Date (mm/dd/yyyy)
[TM1] / Name – Child
[TM2] / Birthdate (mm/dd/yyyy)
[TM3]
Source(s) of Information
[TM4] / Name – Caseworker
[TM5] / Name – Updated By
[TM6]
[TM7] Yes [TM8]No [TM9] UnknownIs there any information to support that a family member has American Indian or Alaska Native heritage?
[TM10]Yes [TM11]No [TM12]UnknownIf “Yes”, is the name(s) of the Indian band or Indian tribe or Alaska Native Village known?
If “Yes”, list tribe(s) / band(s) / village(s).
[TM13]
[TM14]Yes [TM15]No [TM16]UnknownIs the child adopted?
[TM17]Yes [TM18]No [TM19]UnknownIf “Yes”, was either of child’s biological parents American Indian or an Alaska Native?
[TM20]Yes [TM21]No [TM22]UnknownIf “Yes”, is the name(s) of the Indian band or Indian tribe or Alaska Native Village known?
If “Yes”, list tribe(s) / band(s) / village(s).
[TM23]
[TM24]Yes [TM25]No [TM26]UnknownWas either of the child’s biological parents adopted as a child?
[TM27]Yes [TM28]No [TM29]UnknownIf “Yes”, was either parent of either biological parent (child’s biological grandparent) Indian or Alaska Native?
[TM30]Yes [TM31]No [TM32]UnknownIf “Yes”, was the parent told what tribe(s) or village(s) their birth parent was affiliated with? If “Yes”, list tribe(s) / band(s) / village(s).
[TM33]
Instruction
It is important to identify if a child is an Indian child because certain procedures must be followed regarding the case. The following questions will assist you in determining whether a child may be subject to the Indian Child Welfare (ICWA).
1. / [TM34]Yes [TM35]No [TM36]UnknownHas any member of the family ever received services from the Bureau of Indian Affairs? If “Yes”,
complete items below.
Name / Relationship to Child / Location Where Services Received
and Approximate Dates
[TM37] / [TM38] / [TM39]
2. / [TM40] Yes [TM41] No [TM42] UnknownHas any member of the family ever attended an Indian school? If “Yes”, complete items below.
Name / Relationship to Child / Name of School(s) and Approximate Dates Attended / Location of School(s)
[TM43] / [TM44] / [TM45] / [TM46]
3. / [TM47] Yes [TM48] No [TM49] UnknownHas any member of the family ever received medical treatment at an Indian health clinic or Indian Health Service agency or hospital as a beneficiary of the Indian Health Service? If “Yes”, complete items below.
Name / Relationship to Child / Location Where Treatment Received and Approximate Dates
[TM50] / [TM51] / [TM52]
4. / [TM53] Yes [TM54] No [TM55] UnknownHas any member of the family ever lived on federal trust land, a reservation, or a rancheria, or in a pueblo or Alaska Native village? If “Yes”, complete the items below.
Name / Relationship to Child / Name(s) of Reservation / Village, etc. and Location / Approximate Date(s)
[TM56] / [TM57] / [TM58] / [TM59]
5. / [TM60] Yes [TM61] No [TM62] UnknownHas any member of the family ever received educational benefits from the Bureau of Indian Affairs?
If “Yes”, complete items below.
Name / Relationship to Child / Location Where Benefits Received and Approximate Dates
[TM63] / [TM64] / [TM65]
COMMENTS
[TM66]
Instruction
Complete the child’s Biological Family History in accordance with policy.

Screening for Child’s Status as IndianPage 1 of 2

DCF-F-CFS2322-E (R. 04/2010)

[TM1]This field is pre-filled. The field cannot be updated on the template. The data cannot be corrected.

[TM2]This field is pre-filled with the Case Participant identified on the ICWA Record page. The field cannot be updated on the template. The data can be corrected as follows: update the Person Management record for the participant.

[TM3]This field is pre-filled for the Case Participant identified on the ICWA Record page. The field cannot be updated on the template. The data can be corrected as follows: update the Person Management record for the participant.

[TM4]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM5]This field is pre-filled with the worker creating the template. The field cannot be updated on the template. The data can be corrected as follows: update the Person Management record for the worker.

[TM6]This field is pre-filled. The field cannot be updated on the template. The data cannot be corrected.

[TM7]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM8]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM9]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM10]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM11]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM12]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM13]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM14]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM15]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM16]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM17]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM18]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM19]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM20]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM21]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM22]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM23]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM24]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM25]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM26]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM27]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM28]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM29]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM30]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM31]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM32]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM33]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM34]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM35]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM36]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM37]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM38]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM39]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM40]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM41]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM42]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM43]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM44]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM45]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM46]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM47]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM48]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM49]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM50]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM51]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM52]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM53]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM54]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM55]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM56]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM57]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM58]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM59]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM60]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM61]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM62]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM63]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM64]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM65]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.

[TM66]This field is pre-filled. The field cannot be updated on the template. The data can be corrected as follows: update the Screening tab of the ICWA Record page.