ࡱ> _a^ @ @bjbj{{ *NG%lllllll8 4T), !!!!"+#Lw#(e(g(g(g(g(g(g($B*R, (El#""##(ll!!($$$#l!l!e($#e($$ll$! @]S#$9%,(0)$-#-$llll-l$##$#####(( d $ADMINISTRATIVE REVIEW REQUESTFOR DETERMINATION OF CARE (DOC) DENIALMichigan Department of Human ServicesA. IDENTIFYING INFORMATION Child s Name (Last, First, Middle)Birthdate FORMTEXT       FORMTEXT      SWSS Log NumberSWSS Case Number FORMTEXT       FORMTEXT      DHS Worker-Printed NameDHS Worker SignatureLoad Number FORMTEXT       FORMTEXT      DHS Supervisor-Printed NameDHS Supervisor Signature FORMTEXT      Private Agency Name FORMTEXT      Agency Worker-Printed NamePrivate Agency Worker SignatureAgency Worker Email FORMTEXT       FORMTEXT      Agency Supervisor-Printed NamePrivate Agency Supervisor SignatureAgency Supervisor Email FORMTEXT       FORMTEXT      Foster Parent Name FORMTEXT      Foster Parent Address/City/State/Zip FORMTEXT      Foster Parent PhoneFoster Parent Email FORMTEXT      FORMTEXT       FORMTEXT      B. ADMINISTRATIVE REVIEW INFORMATION Da>Bv  z |   & ( * 4 6 8 : N P R \ ^ b º”~ hh)5CJjh-Uh-jh-UjhZ Uhh)OJQJjhdUjhh)Ujh!UmHnHujhdUjhZ UhZ hh)hZ 5 hh)5h~hh)hjd1@Bs6<kd$$Ifl4,,4 lalf4<kdX$$Ifl4,,4 lalf4 $Ifgdjd<kd$$Ifl4p,,4 lalf4 $Ifgd(,@@ s]+v:$ ($If^a$gdd<kd`$$Ifl4,,4 lalf4 $Ifgd(,<kd$$Ifl4,,4 lalf4 $Ifgdjd  d x z ^ ^VG:  $IfgdZ  $IfgdZ Okd$$Ifl40, 4 lalf4  $IfgdZ  $IfgdZ <kd$$Ifl4P,,4 lalf4   8 ` d^PAA $IfgdZ Okd$$Ifl40<,<K4 lalf4 $IfgdZ Okd$$Ifl4P0, 4 lalf4` b ~^ ^ ^0bkd$$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ Okdn$$Ifl4P0<,<K4 lalf4     $ & ( *       ־ַ֨֍־wj hh"U hZ 5CJhZ jL hdUhh)h%Y5hh)hh)5h%Yjhh"U hh)5CJ hh)5jhdUjhh)Uhh)jh!UmHnHujhh"Uhh"jhh"U- ( * b  v:qb~^bY^ $IfgdZ bkdh$$Ifl4PFV,V      4 lalf4  $IfgdZ  $IfgdZ  $IfgdZ  Yv:A2 $IfgdZ Okd$$Ifl4P0V,V14 lalf4 $IfgdZ  $IfgdZ Okd$$Ifl40V,V14 lalf4  +^vg $IfgdZ <kd $$Ifl4,,4 lalf4 $IfgdZ <kdz $$Ifl4,,4 lalf4  P ~^ ^ ^Cbkd. $$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ <kd $$Ifl4P,,4 lalf4  L  v:qbb ^U ^  $IfgdZ  $IfgdZ bkd $$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ  $IfgdZ     :DFH\^`jlnp¾֫ګє֌ցڌz֌oڌjnhZ U hZ hZ j hZ UjhZ Uhh)hZ 5jLh~Uh~jh~Uj hh"Uhh"jhh"U hZ 5CJ hZ 5hZ jh!UmHnHuj< hfrmUh{rjh{rU+ ~ v:q  $IfgdZ  $IfgdZ  $IfgdZ bkd> $$Ifl4FV,V      4 lalf4DP+^<kdN$$Ifl4,,4 lalf4 $IfgdZ bkd$$Ifl4FV,V      4 lalf4DFnpvg+^ $IfgdZ <kd$$Ifl4P,,4 lalf4 $IfgdZ <kd$$Ifl4,,4 lalf46vg~^gY^ $IfgdZ <kd$$Ifl4P,,4 lalf4 $IfgdZ <kd$$Ifl4,,4 lalf468:NPRXZ\^rtv:J:L:`:b:d:n:p:t:::::::ϛyjVh!UjhfrmUhfrmjthh"Ujhh"UUhh"hh)hZ 5hZ hZ 5jhZ Uj<hdUjh!UmHnHujhdUjhZ U hZ 5CJ hZ 5hZ .68P8+v:$ ($If^a$gddOkd$$Ifl4P0V,V14 lalf4 $IfgdZ OkdP$$Ifl40V,V14 lalf4H:J:r:vg $IfgdZ <kd$$Ifl4,,4 lalf4 $IfgdZ <kd$$Ifl4P,,4 lalf4te of Administrative Review Request FORMTEXT      Request Initiated By:Local DHS Office FORMCHECKBOX Private Agency FORMCHECKBOX Foster Parent FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT      C. PLEASE INDICATE IN THE SPACE PROVIDED BELOW A CONCISE SUMMARY OF YOUR REASON FOR REVIEW OF THE DOC DECISION FOR THE ABOVE NAMED CHILD: FORMTEXT      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. 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