disciplinary action unit denial/PROVISIONAL/revocation checklist
Michigan Department of Health and Human Services
Division of Child Welfare Licensing
SECTION I: RECOMMENDATION
Denial	Provisional	Revocation
CWL-3889, Children’s Foster Home License Application	Closing CWL-259, Special Evaluation Record	Closing CWL-259, Special Evaluation Record
CWL-3130, Initial Foster/ Adoption Home Evaluation	CWL-4005, Special Evaluation Report and supporting documents	Current CWL-4005, Special Evaluation Report
CWL-3706, Children's Foster Home Licensing Transaction Record	CWL-3706, Children's Foster Home Licensing Transaction Record	CWL-3706, Children's Foster Home Licensing Transaction Record
Relative Denial Memo (if applicable)	Signed CWL-4617-FH, Acknowledgement of Appeal Rights (FH) or short description of attempts to obtain 4617 & FP refusal	Prior CWL-4005, Special Evaluation Reports
Previous Corrective Action Plans
All CWL-1326’s Licensing Clearances and Results	Approved CAP (any refusal to submit a CAP must recommend revocation)	Most Recent Renewal Application
Foster Parent Correspondence/Written Response
Mail denial documents to your assigned DCWL support staff; do not email denial documents	Submit provisional recommendation documents to MDHHS-DCWL-259@michigan.gov	Submit revocation recommendation documents to MDHHS-DCWL-259@michigan.gov
SECTION II: CPA INFORMATION
Licensing Supervisor	Email
Licensing Worker	Email
SECTION III: APPLICANT/LICENSEE DEMOGRAPHIC INFORMATION
Name	License Number
Cell Phone	Email
Applicant Placement Criteria	Unrelated Relative Both
Licensee Placement Criteria (Select all that apply)	Unrelated Relative Both

SECTION IV: STATUS OF CHILDREN IN APPLICANT/LICENSEE HOME
Are Children Currently Placed in the Home?	Yes No If no, proceed to Section V.
Is Placement Court Ordered?	Yes No
Permanency Plan	Adoption Reunification Guardianship
SECTION V: FOSTER CHILD(REN) DEMOGRAPHICS (also include children removed as a result of this recommendation.)
Name	DOB
Name	DOB
Name	DOB
Name	DOB
Name	DOB
Name	DOB
SECTION VI: LICENSEE SUPPLEMENTAL INFORMATION (if applicable)
Is License to Expire within 60 Days?	Yes No
***CWL-3889 renewal application must be sent to licensees even when revocation is requested***
Expiration Date of License	Date Renewal Application Sent	Date Renewal Application Received
SECTION VII: UPLOAD SUPPORTING DOCUMENTS RELATED TO DISCIPLINARY ACTION
(Check which applicable supporting documents were uploaded/provide location in MiSACWIS)
MiSACWIS Location (specify which tab)
Photographs/Videos
Applicant/Licensee Medical Reports
Applicant/Licensee Mental Health Reports
Children’s Medical/Mental Health Reports
Police/Court Records
Signed Applicable Policies
Previous CPS Reports Not Available in MiSACWIS (Pre-2014)
Financial Documents
Written Safety Plan
Text/Social Media/Email Screenshots
Other Source Documents
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.