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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 R0jn   D J   8 < > R T V ` b d f z | ~ ׾ߘ׾jh-Uh-jh-UjhZ Uhh)OJQJjhdUjhh)UjhUmHnHujhdUjhZ UhZ hh)hZ 5 hh)5hhh)h3hjd1lns6<kd$$Ifl4,,4 lalf4<kdX$$Ifl4,,4 lalf4 $Ifgdjd<kd$$Ifl4P,,4 lalf4 $Ifgd(,==   H s]$ ($If^a$gdd<kd`$$Ifl4,,4 lalf4 $Ifgd(,<kd$$Ifl4,,4 lalf4 $IfgdjdH J VG:  $IfgdZ  $IfgdZ Okd$$Ifl40, 4 lalf4  $IfgdZ  $IfgdZ <kd$$Ifl4P,,4 lalf4  : < d PAA $IfgdZ Okd$$Ifl40<,<K4 lalf4 $IfgdZ Okd$$Ifl4P0, 4 lalf4  0bkd$$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ Okdn$$Ifl4P0<,<K4 lalf4      & ( , . B D F P R T V     2 4 6 @ B D F  ϼϷϨύϷwj hh"U hZ 5CJhZ jL hdUhh)h%Y5hh)hh)5h%Yjhh"U hh)5jhdUjhh)Uhh)jhUmHnHujhh"Uhh"jhh"U hh)5CJ. * , T V qbb $IfgdZ bkdh$$Ifl4PFV,V      4 lalf4  $IfgdZ  $IfgdZ  $IfgdZ  A2 $IfgdZ Okd$$Ifl4P0V,V14 lalf4 $IfgdZ  $IfgdZ Okd$$Ifl40V,V14 lalf4   D vg $IfgdZ <kd $$Ifl4,,4 lalf4 $IfgdZ <kdz $$Ifl4,,4 lalf4D F | Cbkd. $$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ <kd $$Ifl4P,,4 lalf4   8 : x qbbU  $IfgdZ  $IfgdZ bkd $$Ifl4FV,V      4 lalf4  $IfgdZ  $IfgdZ  $IfgdZ   & ( * 4 6 8 :   246@BJfprt bdf¾Ѡ֘֍ژц֘{ژʘjnhZ U hZ hZ j hZ UjhZ Uhh)hZ 5jLhUj hh"Uhh"jhh"U hZ 5CJ hZ 5hZ jhUmHnHuj< hUhjhU0 D~q  $IfgdZ  $IfgdZ  $IfgdZ bkd> $$Ifl4FV,V      4 lalf4DFHJpP<kdN$$Ifl4,,4 lalf4 $IfgdZ bkd$$Ifl4FV,V      4 lalf4prvg $IfgdZ <kd$$Ifl4P,,4 lalf4 $IfgdZ <kd$$Ifl4,,4 lalf4:bvgg $IfgdZ <kd$$Ifl4P,,4 lalf4 $IfgdZ <kd$$Ifl4,,4 lalf4bd&8P8$ ($If^a$gddOkd$$Ifl4P0V,V14 lalf4 $IfgdZ OkdP$$Ifl40V,V14 lalf4fz|~8 8"8(888888888888888888888ۜۜ}h35OJQJjh3Ujh3Ujh3U h3CJh3hh)hZ 5U hZ 5hZ hZ 5jhZ Uj<hdUjhUmHnHujhZ UjhdUhZ /EVIEW INFORMATION Date of Administrative Review RequestDate of DOC Request FORMTEXT       FORMTEXT      C. PLEASE INDICATE IN THE SPACE PROVIDED BELOW A CONCISE SUMMARY OF YOUR REASON FOR DENIAL 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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