Request for Temporary Physical Custody or Pick-Up Order

Name - Worker
[TM1] / Telephone Number
[TM2] / County
[TM3] / Site / Zone
[TM4]
Court Number
[TM5]
I. /

Family Composition

1. / CHIPS ChildChildren[TM6] - List oldest child first.

START_DYNAMIC_TABLE=DetainedChildInfo

ChildJuvenile[TM7]
Name (Last, First, MI)
[TM8] / Birthdate
[TM9] / Age
[TM10]
Address (Street, City, State, Zip Code)
[TM11] / Telephone Number [TM12]
[TM13]
Mother [TM14] Unknown [TM15] Deceased
Name (Last, First, MI) Status: [TM16] Birth [TM17] Adoptive
[TM18] / Birthdate
[TM19]
Address (Street, City, State, Zip Code)
[TM20] / Telephone Number [TM21]
[TM22]
Marital Status
[TM23] Married [TM24] Single [TM25] Widowed [TM26] Divorced / Name - Spouse
[TM27]
Father [TM28] Unknown [TM29] Deceased
Name (Last, First, MI)
[TM30] / Birthdate
[TM31]
Address (Street, City, State, Zip Code)
[TM32] / Telephone Number [TM33]
[TM34]
Marital Status
[TM35] Married [TM36] Single [TM37] Widowed [TM38] Divorced / Name - Spouse
[TM39]
Status: [TM40] Adjudicated [TM41] Adoptive [TM42] Alleged [TM43] Presumptive

END_DYNAMIC_TABLE=DetainedChildInfo

2. / List any other children who are part of this family but have not been taken into Temporary Physical Custody at this time.
This includes adult children, and children who have been previously involved in a termination of parental rights.
Name - Child / Birthdate / Address - Include Zip Code

START_DYNAMIC_TABLE=NonDetainedChildInfo

[TM44] / [TM45] / [TM46]

END_DYNAMIC_TABLE=NonDetainedChildInfo

3. / Guardian, Legal Custodian, or Indian Custodian if different than natural parents: relationship, where and when order made. [TM47]

START_DYNAMIC_TABLE=GuardChildInfo

Name – Child
[TM48]

START_DYNAMIC_TABLE=GuardianInfo@

Name - [TM49]
[TM50] / Address
[TM51]

END_DYNAMIC_TABLE=GuardianInfo@

END_DYNAMIC_TABLE=GuardChildInfo

4. / Date and time of decision to hold in custody.
Case must appear before the Court within 48 hours of the date and time listed below.
Date (mm/dd/yyyy)
[TM52] / Time
[TM53]
5. / [TM54] / Yes / [TM55] / No /

Is disclosure of location dangerous to child or custodian?

If "Yes", explain why the disclosure would result in imminent danger to the child or physical custodian.

[TM56]

6. / Where isare[TM57] the childchildren[TM58] presently placed?

START_DYNAMIC_TABLE=PlacementInfo

Current Caregiver
Name - Child (Last, First, MI)
[TM59]
Name - Caregiver 1 (Last, First, MI)
[TM60] / Name - Caregiver 2 (Last, First, MI)
[TM61] / Relationship to ChildJuvenile[TM62]
[TM63]
Address (Street, City, State, Zip Code)
[TM64] / Telephone Number
[TM65]

END_DYNAMIC_TABLE=PlacementInfo

7. / Placement Requested
[TM66] / Home of Parent or Guardian / [TM67] / Adolescent Assessment Center or Placement Stabilization Center
[TM68] / Home of Relative / [TM69] / Home of Non-Relative
[TM70] / Foster Home or Treatment Foster Home / [TM71] / Other Non-Secure Facility
[TM72] / Hospital (excluding psychiatric)
8. / Other Orders Requested

[TM73]

9. / Visitation Required - Check one.
[TM74] / At the discretion of the Agency
[TM75] / Supervised by the Agency or an approved adult
[TM76] / Upon mutual desire
10. / List all the people who will appear at the emergency hearing. Note: All children 12 years of age and older must appear.

[TM77]

II. /
Worksheet
1. / [TM78] / Yes / [TM79] / No / Is there a language barrier?
If "Yes", what is the primary language spoken by the: / ParentParents[TM80] - [TM81] / ChildChildren[TM82] - [TM83]

START_DYNAMIC_TABLE=TribalInfo

2. / Name: [TM84]
[TM85]Yes [TM86] No / Is the childjuvenile[TM87]an American Indian?
If Yes, name of American Indian Tribe or Band: [TM88]

END_DYNAMIC_TABLE=TribalInfo

[TM89] Yes [TM90] No / If the above child ischildren arejuvenile isjuveniles are[TM91] American Indian, has the Tribehave the Tribes[TM92] been notified of these proceedings?
Verification of American Indian status provided by: [TM93]
3. / [TM94] / Yes / [TM95] / No / Was written notification given to parents, guardians, and / or tribe? If "Yes", specify where and when.

[TM96]

4. / List the date and time the Department received the current referral.
Date (mm/dd/yyyy)
[TM97] / Time
[TM98]
5. / Summarize [TM99] history or out of town court activity. Include findings, dates, placements, orders, etc.

[TM100]

NOTE: If there is a dispositional order, complete the information below.
On [TM101] said childchildrensiblings[TM102][TM103][TM104]waswere[TM105] found to be in need of protection or services pursuant to Wis. Stats. s. 48.13 ([TM106]). Based upon finding, the Honorable [TM107]transferred legal custody of said child totransferred legal custody of said children toordered placement by[TM108][TM109] for a period of [TM110]. That order now expires on [TM111]. Said child waschildren were[TM112] placed with [TM113] under the court's order.
6. / List parents' criminal court contacts.

[TM114]

7. / Family Information(Who are the household members; what are their DOB’s; what is their usual address; what is the current location of each family member (if different from their usual address); are there additional family members who are not typically part of the household who are now involved, if so who are they and how are they involved; and what are the family’sfinancial resources (employment, child support, social security benefits, etc.?)

[TM115]

8. / What was the original cause for concern that led the Bureau to make contact and intervene?

[TM116]

9. / Detailed description of the actions taken (TPC) to protect the child(ren) and why, including options considered to prevent removal (i.e. Danger threats identified; options considered, available, appropriateness; caregiver involvement in the decision; and location of the children)

[TM117]

10. / Summary of the incident based on Bureau contacts and information gathered (i.e. Who went out to gather information; who was observed, interviewed, over what span of time; and what are the conclusions thus far regarding what happened, how it happened, explanations and attitudes of principle parties, effects on the children?)

[TM118]

11. / Any pertinent history that supports the premise that the incident may not be an anomaly and/or the dangerous conditions are a pattern?

[TM119]

12. / Information gathered thus far that helps understand more than the incident: (i.e. The general functioning of all the children; the general functioning of all the adult caregivers; the general approach to and methods of discipline used; the general parenting by the adult caregivers; and other forms of maltreatment that may be happening)

[TM120]

13. / Justification for Recommendations at hearing (i.e. Why continuing/discontinuing TPC? How does information gathered between the date of taking TPC and the TPC hearing support the continuance/discontinuance of TPC? Frequency and type of family contact between the TPC hearing and the next hearing?)

[TM121]

14. / Next steps recommended for inclusion in the order (i.e. Any immediate child/family needs that must be addressed; continued information gathering by Bureau; and cooperation by family with next steps)

[TM122]

15. / List all witnesses and information they will provide, including records or pictures available; e.g., hospital, doctor, school, etc.

[TM123]

16. / What is your plan at this time?

[TM124]

III. /
Signatures
[TM125]
Name - Worker
SIGNATURE - Worker / Date Signed
[TM126]
Name - Supervisor
SIGNATURE - Supervisor / Date Signed

DCF-F-CFS2071-E (R. 06/2014)Page 1 of 3

[TM1]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the worker’s name can be updated (by supervisor) on the Person Management page/Basic tab.

[TM2]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the worker’s phone number can be updated (by supervisor) on the worker's Maintain Worker Information page.

[TM3]11This field is pre-filled.

This field is not editable on the template.

This field can be corrected as follows: The County pre-fills with the county name of the worker who created the template. If this is incorrect, the worker's supervisor needs to update the worker's county in the worker's Maintain Worker Information page.

[TM4]11This field is pre-filled.

This field is not editable on the template.

This field can be corrected as follows: 1the site/zone can be changed (by supervisor) in the worker's Maintain Worker Information page.

[TM5]1This field is user-entered.

This field can be updated on the template.

[TM6]1This field is user-selected. The values are: [Child], [Children].

This field can be updated on the template.

[TM7]1This field is user-selected. The values are: [Child], [Juvenile].

This field can be updated on the template.

[TM8]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: a change to the Role can be updated/modified in the Document group box on the Legal Documentation page.

[TM9]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the child’s Birth Date can be changed in the Birth Date field on the Person Management page/Basic tab.

[TM10]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the child’s age will be re-calculated if the birth date is changed in the Birth Date field on the Person Management page/Basic tab.

[TM11]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the child’s address can be changed in the Address field on the Person Management page/Address tab. The Address follows a hierarchy rule. It first looks for a Primary Residence address, followed by Secondary Residence address, then Mailing address, then Work address, and finally Last Known address.

[TM12]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the telephone number can be changed in the Phone field on the Person Management page/Address tab. If the phone number is derived from a Cell field then it will display ‘Cell’, regardless of the address type. If the number if coming from a Work address then this field will display ‘Work’. Otherwise it will display ‘Home.’

[TM13]1This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the telephone number can be changed in the Phone field on the Person Management page/Address tab. The Telephone Number follows a hierarchy rule. It first looks for phone numbers on the Primary Residence address, followed by Secondary Residence, then Mailing address, then Work address, and finally Last Known address.

[TM14]1This field is user-entered.

This field can be updated on the template.

[TM15]1This 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]111This field is pre-filled.

The field is not editable on the template.

The data can be corrected as follows: Update the mother's name on the Basic tab of the mother's Person Management page. The child's Mother is identified on the Parent Info tab of the mother's Person Management page.

[TM19]1111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the mother's Birth Date on the Basic tab of the mother's Person Management page. The child's Mother is identified on the Parent Info tab of the child's Person Management page.

[TM20]This field is pre-filled.

This field is not editable on the template. The data can be corrected as follows: the mother’s address can be changed in the Address field on the Person Management page/Address tab. The Address follows a hierarchy rule. It first looks for a Primary Residence address, followed by Secondary Residence address, then Mailing address, then Work address, and finally Last Known address.

[TM21]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the telephone number can be changed in the Phone field on the Person Management page/Address tab. If the phone number is derived from a Cell field then it will display ‘Cell’, regardless of the address type. If the number if coming from a Work address then this field will display ‘Work’. Otherwise it will display ‘Home.’

[TM22]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the telephone number can be changed in the Phone field on the Person Management page/Address tab. The Telephone Number follows a hierarchy rule. It first looks for phone numbers on the Primary Residence address, followed by Secondary Residence, then Mailing address, then Work address, and finally Last Known address.

[TM23]1111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Mother’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM24]1111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Mother’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM25]1111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Mother’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM26]1111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Mother’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM27]111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update in the Mother’s Spouse field on the Parent Info tab of the child's Person Management page.

[TM28]1This field is user-entered.

This field can be updated on the template.

[TM29]1This field is user-entered.

This field can be updated on the template.

[TM30]1111This field is pre-filled.

The field is not editable on the template.

The data can be corrected as follows: Update the Basic tab of the father's Person Management page. The child's Father is identified on the Parent Info tab of the child's Person Management page.

[TM31]1111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the father's Birth Date on the Basic tab of the father's Person Management page. The child's Father is identified on the Parent Info tab of the child's Person Management page.

[TM32]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the father’s address can be changed in the Address field on the Person Management page/Address tab. The Address follows a hierarchy rule. It first looks for a Primary Residence address, followed by Secondary Residence address, then Mailing address, then Work address, and finally Last Known address.

[TM33]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the telephone number can be changed in the Phone field on the Person Management page/Address tab. If the phone number is derived from a Cell field then it will display ‘Cell’, regardless of the address type. If the number if coming from a Work address then this field will display ‘Work’. Otherwise it will display ‘Home.’

[TM34]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: the telephone number can be changed in the Phone field on the Person Management page/Address tab. The Telephone Number follows a hierarchy rule. It first looks for phone numbers on the Primary Residence address, followed by Secondary Residence, then Mailing address, then Work address, and finally Last Known address.

[TM35]111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM36]111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM37]111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM38]111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Current Marital Status field on the Parent Info tab of the child's Person Management page.

[TM39]This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update in the Father’s Spouse field on the Parent Info tab of the child's Person Management page.

[TM40]11111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Type field on the Parent Info tab on the child's Person Management page1.

[TM41]11111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Type field on the Parent Info tab on the child's Person Management page1.

[TM42]11111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Type field on the Parent Info tab on the child's Person Management page1.

[TM43]11111111This field is pre-filled.

This field is not editable on the template.

The data can be corrected as follows: Update the Father’s Type field on the Parent Info tab on the child's Person Management page1.

[TM44]1This field is pre-filled with the name of the child with a role of "Child (Not Detained)".

This field is not editable on the template.

The data can be corrected as follows: a change to the Role can be updated/modified in the Document group box on the Legal Documentation page.

[TM45]1This field is pre-filled with the Birthdate of the child with a role of "Child (Not Detained)".This field is not editable on the template. The data can be corrected as follows: the child’s Birth Date can be changed in the Birth Date field on the Person Management page/Basic tab.

[TM46]1This field is pre-filled with the address of the child with a role of "Child (Not Detained)". This field is not editable on the template. The data can be corrected as follows: the child’s address can be changed in the Address field on the Person Management page/Address tab.The Address follows a hierarchy rule. It first looks for a Primary Residence address, followed by Secondary Residence address, then Mailing address, then Work address, and finally Last Known address.

[TM47]11This field is user-entered.

This field can be updated on the template.