ࡱ>  #qy bjbj *~{{)P l ZZZZZnnn8dn6E: <%!$I!ACCCCCC$FICZ]! ]!]!CZZ D_,_,_,]!FZZ A_,]!A_,_,<|O>b !FS=AE06Ee=PJ!>PJ$O>PJZ]>]!]!_,]!]!]!]!]!CC''8]!]!]!6E]!]!]!]!PJ]!]!]!]!]!]!]!]!]! : INITIAL RELATIVE SAFETY SCREENMichigan Department of Human ServicesRelative Caregiver(s) NameMaiden Name, Aliases, AKA (if applicable)Relative Caregiver(s) Date of Birth1. FORMTEXT       FORMTEXT       FORMTEXT      2. FORMTEXT       FORMTEXT       FORMTEXT      Relative Caregiver(s) AddressRelative Caregiver(s) PhoneDate of Home Visit FORMTEXT       FORMTEXT       FORMTEXT      Name of Child(ren) Placed and his/her Relationship to the Relative CaregiverChild Case NumberSWSS Log # FORMTEXT       FORMTEXT       FORMTEXT      List all Adults Living in the Home and Dates of Birth  FORMTEXT      Case Worker NameCase Worker PhoneCase Worker Load # FORMTEXT       FORMTEXT       FORMTEXT      DHS County or PAFC Provider Name FORMTEXT      Central Registry CheckDate of Central Registry Check: FORMTEXT       FORMCHECKBOX No adult in the home is listed as a perpetrator on central registry in Michigan. FORMCHECKBOX The caregiver(s) has resided in other states. (Central registry clearances must be requested within 72 hours.) Name of state(s): FORMTEXT      Date of Out-of-State Central Registry Checks: FORMTEXT       FORMCHECKBOX The following adult(s) in the home is listed as the perpetrator on central registry and placement cannot be made. FORMTEXT      Multiple CPS Investigations:Date of SWSS CPS clearance: FORMTEXT       FORMCHECKBOX No member(s) of the household has multiple CPS investigations wherein he/she is indicated as an alleged perpetrator in the home. FORMCHECKBOX The following adult(s) in the household has multiple CPS investigations and is indicated as the alleged perpetrator. Placement cannot be made until the multiple CPS investigations assessment is completed and approved by the county director.Names:DOB: FORMTEXT       FORMTEXT      Multiple CPS Investigations Assessment:Describe the length of time since last investigation and any services that were provided to rectify the problem(s). FORMTEXT      If services were provided, determine if the household member(s) benefitted and completed services successfully. FORMTEXT      Address any risk factors that might impact the safety of the child and describe what protective interventions are currently in place. FORMTEXT      NOTE: Child safety must be assessed during contact with the relative considering this CPS information. State Criminal History Check*Date of criminal clearance: FORMTEXT      *Criminal history checks must include I-CHAT and Sex Offender Registry. The caregiver s name and home address must be check on the sex offender registry. FORMCHECKBOX No member of the household has a felony conviction for one of the following crimes:Child abuse/neglect Spousal abuse Crime against children (including pornography).A crime involving violence, including rape, sexual assault or homicide but not including other physical assault or battery. A physical assault or battery within the last five years. A drug related offense within the last five years. FORMCHECKBOX The following member(s) of the household has a felony conviction for one of the offenses listed above and placement is prohibited.NameOffenseDate of Conviction FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX An adjudicated sex offender resides in the home and placement is prohibited. FORMCHECKBOX The relative caregiver(s) or other member of the household has a conviction more than 5 years but less than 10 years ago for one or more of the following good moral character offenses: (See BCAL Pub-673, Good Moral Character, for additional information.)1.Misdemeanor or felony crimes of violence (robbery, burglary, arson, kidnapping, assault, battery, etc.)2.Felony drug or alcohol related offenses.NameOffenseDate of Conviction FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Note: Placement is not prohibited but requires further assessment. Placement cannot be made until the criminal convictions assessment has been completed and approved by the county director.Criminal Convictions Assessment:Describe length of time since the offense, the relationship of the conviction to caring for children and any services that were provided to rectify the problem(s) FORMTEXT      If services were provided, determine if the household member(s) completed the service(s) successfully. FORMTEXT      Document how the offense may impact the safety of the child(ren) placed in the home. Address any risk factors that might impact the safety of the child(ren) and describe protective interventions currently in place. This documentation must describe and support the basis for the approval, and why the child(ren) is safe in the relative s home. FORMTEXT       Safety of PlacementThe worker has observed and verified the following:YesNo1. FORMCHECKBOX  FORMCHECKBOX There are enough beds so there are no more than 2 same gendered related children sharing a bed. (If 2 related children share a bed it must be larger than a twin bed.)2. FORMCHECKBOX  FORMCHECKBOX The bedrooms have a window that is large enough to be used for egress; finished ceiling: floor-to-ceiling permanently affixed walls, and finished flooring (i.e. carpeted, finished wood, etc.).3. FORMCHECKBOX  FORMCHECKBOX The relative has a source of income to meet the familys needs (e.g. food, shelter and clothing).4. FORMCHECKBOX  FORMCHECKBOX There is a plan for age appropriate children to have supervision at all times even when the relative is absent from the home.5. 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FORMCHECKBOX  FORMCHECKBOX All entrances/exits to and from the home are unobstructed.7. FORMCHECKBOX  FORMCHECKBOX The home is able to meet the child s health care needs. (e.g., child has allergies to smoke and the household is smoke free, etc.)8. FORMCHECKBOX  FORMCHECKBOX The home is free from observable health/sanitation risks (e.g. flushable toilets, nonsoiled mattresses, etc.).9. FORMCHECKBOX  FORMCHECKBOX The home is free from observable safety hazards (e.g., broken windows, exposed wires, etc.).10. FORMCHECKBOX  FORMCHECKBOX If applicable, all weapons and ammunition are locked up in a separate room and inaccessible to children.11. FORMCHECKBOX  FORMCHECKBOX All cleaning supplies, medicines, and/or any other dangerous chemicals are inaccessible.12. FORMCHECKBOX  FORMCHECKBOX There is an accessible working phone in the home (includes cell phone).13. FORMCHECKBOX  FORMCHECKBOX Basic utilities (water, electricity, heating) are in operating condition?14. FORMCHECKBOX  FORMCHECKBOX The caregiver is able to manage his/her own daily living activities, such as, preparing meals, housekeeping, shopping for groceries, bathing, etc.? Verify by asking if the caregiver receives home health services. (Home health services requires an individual to assist the caregiver with daily living activities.)15. FORMCHECKBOX  FORMCHECKBOX Other placement concerns are identified. There has been reported incidents of domestic violence or has a history of domestic violence involving the caregiver or any other household member. Describe: FORMTEXT      The caregiver or adult residing in the home has a substance use/alcohol concern or has a history of substance/alcohol abuse and/or treatment. Describe: FORMTEXT      There are mental and/or emotion health concerns that would impair the caregiver s ability to provide for the child(ren) s physical or emotional safety and well-being. Describe: FORMTEXT      The caregiver has a physical health condition that would affect the care of the child(ren) in the home. Describe: FORMTEXT      Other. Describe: FORMTEXT      16. FORMCHECKBOX  FORMCHECKBOX The benefits of licensure have been discussed with the relative (DHS-972, Foster Home Licensing Requirements for Relative Caregivers has been signed.)17. FORMCHECKBOX  FORMCHECKBOX The relative is willing and able to provide long-term placement, if necessary.18. FORMCHECKBOX  FORMCHECKBOX The relative is being considered for an infant 0-12 months of age. The relative has been informed of safe sleep guidelines and was provided the Infant Safe Sleep brochure.If No is checked in boxes 1-14, provide an explanation of the safety concern. Indicate if the relative is able and/or willing to resolve the safety concern within a reasonable period of time. If so, list the action to be taken and the anticipated date of completion. Placement cannot be made until the safety concern is resolved. FORMTEXT      If Yes is checked in box 15, note placement decision & specify rationale for final recommendation. FORMTEXT      If No is checked in box 16, provide explanation. FORMTEXT       By signing below, I acknowledge my home had an initial safety assessment and the caseworker has reviewed the findings with me.Caregiver(s) SignatureDateSignature of CaseworkerDateSignature of SupervisorDateSignature of County Director (if applicable)DateApproved  FORMCHECKBOX Denied  FORMCHECKBOX Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.     DHS-588 (Rev. 1-12) Previous edition obsolete. 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L^`LhH.h hh^h`o(hH.h88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh hh^h`o(hH.h88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHhhh^h`OJQJo(hHh88^8`OJQJ^Jo(hHoh^`OJQJo(hHh  ^ `OJQJo(hHh  ^ `OJQJ^Jo(hHohxx^x`OJQJo(hHhHH^H`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHK{" $wo0a e0SU                  ؾf                                    @k5h * >b 0{f|AHXFSc0\{I *B-*\*,| ,(,B.%/mF/^/T 092{;2^2`4P576O7XP7ys7r+8r:0]<DclFZHws;iy"GJo(\\5+z:4))V .^:.^V .^:.^  Spell Check Spell CheckLfQ+LfQ+LfQ+LfQ+LfQ+1(  Spell CheckForms Spell Check2Module1.FormsSpellCheck2gTemplateProject.MyInfo.Main(TemplateProject.Module1.FormsSpellCheck2 TEMPLATEPROJECT.MYINFO.MAIN (TEMPLATEPROJECT.MODULE1.FORMSSPELLCHECK2@ @{ h)00 0 000000000<@0 0"0H@0&0P@0*0,0\@0UnknownG* Times New Roman5Symbol3. * Arial?= * Courier New5. *aTahoma;WingdingsA$BCambria Math"h#FFF]S""J""Jr c#r4))=D3QHP?(V*!xx (DHS-0588, Initial Relative Safety ScreenForms and Mail Management martinezl$      ^l Oh+'0 0< \ h t ,DHS-0588, Initial Relative Safety ScreenForms and Mail Management 0588.DOT martinezl93Microsoft Office Word@!v@6@"p-~@6""՜.+,04 hp  (Michigan Department of Human ServicesJ) )DHS-0588, Initial Relative Safety Screen Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Qa    r!"F%@'()*+,-./0123456789:;<=>?ABCDEPHIJKLMNORSTUVWXYZ[\]^_`bcdefghijklmnopstuvwxyz{|}~Root Entry F* $Data ʌ1TableWordDocument*~SummaryInformation( DocumentSummaryInformation8Macros   VBA   dir-MyInfo &2Module1 ThisDocument *  !"#$%&'()+,-./0123456789;<=>?@ABDF)0* pHdTemplateProjectQH@  = | gO J< 9stdole>stdoleP h%^*\G{00020430-C 0046}#2.0#0#C:\WINDOWS\System32\e2.tlb#OLE Automation0MSForms>SFFrms3ED452EE1-E08F-101A-8-02608C4D0BB 4EsEFM20.DLL#Microsoft :" ^ Ob Library/;D1uA00}#0#Gk0 BC6F5CDF-A31B-46B1-ADE7-01DCE61 3F86DOCUME~1\MARTINLOCA LS\Wor d8.0\U.exd =".E .``M OfficOfQ@ic 22DF8D04C-5BFAAi@B-BDE5KAjA422gram Files\CommoniShared\OFFICE145O r& =Lr@%5BThisDocumentG Ti"Dcuen 2 (HB1B-XB,T5""+rM@yInfoG MPyIfM2 M' u ! "oodule1G$oou€1Cs2b"\5xG'5uxMEx &@`Enter Personal InformationNormal.MyInfo.Main@( ~1P*05P,2P.P08.P2P4P6P8p P:``P<``P>`pP@pPB``PD``PFP@PHPJPLPN@``\ `` " (08@HPX`hpx &((0*X&(&&((&P$x&$$&$@&h&(N$0$X&&*$"(0PT$$(H hx <468H6864(6`846 4@ 2x 2 4 2 4X : : 2 H ` & 4 6 8 6P 8 6 4 60 8h 4 6 42H2424(:`: "0284p2420P2402 0X..0.0H6x6 ":>PB>F2`:>66P.2::02p62BF` 4 2 & (@ *h .  2 4 X ` p ]x]]]]]]] ]8]P]h]]]]]]]](]@DEFINE DIALOG BOXF,MyInfo PB@Rm ^YourName PB@Tm8^ YourTitle PB@TmP^ YourOffice PB@Tmi^ YourAddress PB@T>xYourCity PB@TT( YourState PB@TFYourZip PB@Tn(AreaCode PB@TP YourPhone PB@T<YourExt PB@Tr(FAXAC PB@TPYourFax PB@T(YourCO PB@T(YourDI PB@T(YourSEC PB@TT(YourUN PB@T(YourWKR PB@Tm^BossName PB@Tm^ BossTitle PB@Tk  /Enter the following information about yourself. PB@d#2 Name: PB@d;2 Title: PB@dR< Office: PB@dkU Address: PB@d City-ST-Zip: PB@d7 Phone: PB@d>% FAX: PB@dCO-DI-SEC-UN-WKR: PB@dK 6Enter the following information about your supervisor. PB@d2 Name: PB@d 2 Title: PB@d X PB@V"X PB@X PB@Z]XF P!^!`.\6GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOXUserInfoName MYINFO.ini P%d \(bUserInfoTitle MYINFO.ini P%d \(fUserInfoAreaCode MYINFO.ini P%d \(.UserInfoPhone MYINFO.ini P%d \(hUserInfoYourExt MYINFO.ini P%d \(2UserInfoFaxAC MYINFO.ini P%d \(4UserInfoFax MYINFO.ini P%d \(6UserInfoOffice MYINFO.ini P%d \(jUserInfoAddress MYINFO.ini P%d \(lUserInfoCity MYINFO.ini P%d \(nUserInfoState MYINFO.ini P%d \(pUserInfoZip MYINFO.ini P%d \(rUserInfoCO MYINFO.ini P%d \(tUserInfoDI MYINFO.ini P%d \(vUserInfoSEC MYINFO.ini P%d \(xUserInfoUN MYINFO.ini P%d \(zUserInfoWKR MYINFO.ini P%d \(|UserInfo Boss Name MYINFO.ini P%d \(LUserInfo Boss Title MYINFO.ini P%d \(N,DISPLAY DIALOG BOX AND RESPOND TO USER INPUT \ P!~%`'( ( OK BUTTONWRITE NEW USER INFO IN INI FILEUserInfoName \!b MYINFO.ini PB@UserInfoTitle \!f MYINFO.ini PB@UserInfoAreaCode \!. MYINFO.ini PB@UserInfoPhone \!h MYINFO.ini PB@UserInfoYourExt \!2 MYINFO.ini PB@UserInfoFaxAC \!4 MYINFO.ini PB@UserInfoFax \!6 MYINFO.ini PB@UserInfoOffice \!j MYINFO.ini PB@UserInfoAddress \!l MYINFO.ini PB@UserInfoCity \!n MYINFO.ini PB@UserInfoState \!p MYINFO.ini PB@UserInfoZip \!r MYINFO.ini PB@UserInfoCO \!t MYINFO.ini PB@UserInfoDI \!v MYINFO.ini PB@UserInfoSEC \!x MYINFO.ini PB@UserInfoUN \!z MYINFO.ini PB@UserInfoWKR \!| MYINFO.ini PB@UserInfo Boss Name \!L MYINFO.ini PB@UserInfo Boss Title \!N MYINFO.ini PB@Get user info from INI fileUserInfoName MYINFO.ini P%d' *UserInfoTitle MYINFO.ini P%d' ,UserInfoAreaCode MYINFO.ini P%d' .UserInfoPhone MYINFO.ini P%d' 0UserInfoYourExt MYINFO.ini P%d' 2UserInfoFaxAC MYINFO.ini P%d' 4TakUserInfoFax MYINFO.ini P%d' 6UserInfoOffice MYINFO.ini P%d' 8UserInfoAddress MYINFO.ini P%d' :ioUserInfoCity MYINFO.ini P%d' <UserInfoState MYINFO.ini P%d' >UserInfoZip MYINFO.ini P%d' @UserInfoCO MYINFO.ini P%d' BUserInfoDI MYINFO.ini P%d' DUserInfoSEC MYINFO.ini P%d' FUserInfoUN MYINFO.ini P%d' HUserInfoWKR MYINFO.ini P%d' JUserInfo Boss Name MYINFO.ini P%d' LUserInfo Boss Title MYINFO.ini P%d' N Update Form with user info WorkerName P%G workerName * PB@j WorkerTitle P%G WorkerTitle , PB@jWorkerAreaCode P%GWorkerAreaCode . PB@j WorkerPhone P%G WorkerPhone 0 PB@jWorkerExtension P%GWorkerExtension 2 PB@jFaxAC P%GFaxAC 4 PB@j WorkerFax P%G WorkerFax 6 PB@j Countynumber P%G Countynumber B PB@jeDistrict P%GDIstrict D PB@jSection P%GSECtion F PB@jUnit P%GUNit H PB@jiWorker P%GWorker J PB@j CountyName P%G CountyName 8 PB@j CoAddress P%G CoAddress : PB@jelsCoCity P%GCoCity < PB@jCoState P%GCoState > PB@jCoZip P%GCoZip @ PB@jompSupervisorName P%GSupervisorName L PB@jSupervisorTitle P%GSupervisorTitle N PB@j. Update other Form Fields on Form & Exit Macro- Selected$=GetFormResult$ ("CurrentDate")! TheSerialDate = Today() + 14$ TheDate$ = Date$(TheSerialDate)& SetFormResult "DueDate", TheDate$) EditGoTo "CreateDate" : UnlinkFields EditGoTo "GranteefirstName"- ToolsProtectDocument .NoReset = 1, .Type = 2/ ToolsProtectSection .Section = 2, .Protect = 0d FileClose 2 SelectName = - 1kpoh`(Attribute VB_Name = "MyInfo" Public Sub Main(X) D.nDescription|Enter Personal rma:zProcDataIInvoke _FuncINoi8l..nADim iRet B  User$ATitleAreaCod-PhonYourExtFax|AC Offic $AddressCitByStat Zip ODILSEB;UN WKRBoss|| 'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 300,} G TextBox 109@ A 5@ 18@ I @ey 56 * 83 _[ 105WDi 2A3321A5r 34 _  | 9 7 @ 1$55E [1 Pi 23` 6i`cV3jFAXAC41e lV1@,CO629 *DI7m pV? UN6z4!l1.yVm23n`~64`'Fz7,, c3z#the followin`g infa@bout ys0elf. ", ׂ !:w5f"bC #1z0@8O$351{1A-ST- u5 abm3r13@? gY  ;"C O-DI-T-U,N-@H47224*; supervisor!a 124f6p6iOKButtY48 8pR21 fCanctel3kEndn ҂dlg!u! As Object: Se$t = CurValues. vGET USER INFO FROMI FILE AND@ PUT I NTOzx.t[GetPrivfileS@@ng$](" "'P:qMY.ini"r hl ? pa"4??>? Mpn_1r &.nAC `axU/-Y??>OMA\C$$a&gp Op | DIpp/-UN0 | {p y QaserInfo", "Boss Name`MYINFO.ini") dlgU.Title = WordBasic.[GetPrivateProfileString$]("t| 'DISPLAY DIALOG BOX AND RESPOTO USER INPUT iRet Dialog.p (If 3-1 Then 'OK BUTTON ?WRI@TE NEW3FO6I FILE xSx wYour ?, - -AreaCod|PhonEExtE@FaxACL+@OfficZ|Address0$ L+gCity ? : |StP  z Zo%  CoCity  ! CoStat$c b CoZip  "Supervi8sor<`, Boss! /Titl% b ' Upd. other  FieldsH on& t Macro Rem" SelA}ed$=G$ ("Curre8ntD9'`Serial = Today() + 14$5()lDure",a"GEditGoTo 0"Cre : Unlink'Grante@efirst3"ToolsProtDocum! .No@et`1, .Type@2/ .8= 2 `0 Else#FileClose D c.@- 1$nd #Sub ME(<<< <h  Xet%"  .@Pp &x  (((P X h]@'If document is protected, Unprotect it. ! cladd87 B@kPerform Spelling/Grammar check. (DE  !F, !(B@ !B@8.  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