Family Violence Questionnaire Form PDF Details

Are you concerned about family violence in your community? Looking for ways to help prevent and address the issue? If so, consider using a family violence questionnaire form to get a better understanding of the situation. A questionnaire form can help identify patterns and trends in family violence, as well as provide information on who is affected and where they are located. This information can then be used to develop prevention strategies and support services.

QuestionAnswer
Form NameFamily Violence Questionnaire Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessupport ren violence get, california family dcss, california dcss 0048 form, family dcss

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF CHILD SUPPORT SERVICES

FAMILY VIOLENCE QUESTIONNAIRE

DCSS 0048 (02/02/09)

INSTRUCTIONS: If you do not complete and return this form to us, the Department of Child Support Services, or the federal government, may give information about your case to courts, child support agencies, and possibly to the child(ren)’s other parent or party.

Your name:

 

Case Number:

Other party’s name:

SECTION I: Check the appropriate box for each of the questions.

1.Have you or the child(ren) in this case ever been a victim of family violence or child abuse committed by the other party in this child support case?

2.Do you have a restraining order, emergency protective order or stay away order against the other party in this child support case?

If yes, please attach a copy of this order and provide the following information:

County/State:

 

Order/Docket Number:

Expiration Date:

3.If you or the child(ren) in this case receive public assistance, do you want the welfare department to review this case to determine eligibility to close this support case because of the increased risk of physical, sexual, or emotional harm to you or the child(ren) in this case, by the other party? This is called having “good cause” to close the support case.

Yes No

Yes No

Yes No

SECTION II: You MUST complete this section if you answered “Yes” to any item in SECTION I.

Please provide detailed family violence information including dates, times, places, and witnesses. (Attach additional page if needed).

Page 1 of 2

STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

DEPARTMENT OF CHILD SUPPORT SERVICES

FAMILY VIOLENCE QUESTIONNAIRE

DCSS 0048 (02/09/09)

SECTION III: If appropriate please check the box below, sign, date, and return this form to:

Local Child Support Agency

Giving out my address or other information identifying my location could be harmful to me or the child(ren) in this case. I am requesting that my address or other identifying information not be given to the other party in this case. This request will stay in effect until I let the local child support agency know in writing that they may now give out my information, and the local child support agencyt tells me that they have received my request. I understand that under federal law, an authorized person may make a written request to the court that has jurisdiction to make or enforce child support or visitation determinations, for release of my information. The local child support agency will let me know in writing if the court orders the release of any information on my case.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

PRINT NAME

SIGNATURE

DATE

PRIVACY NOTICE

The Information Practices Act of 1997 (Civil Code §1798.17) and the Federal Privacy Act of 1974 (Title 5, United States Code §552a (e)(3), §7 Note) require that this notice be provided when collecting personal information from individuals. Information requested on this form is used by the Department of Child Support Services and local child support agencies for the purpose of safeguarding information from disclosure in domestic and/or child abuse situations. The information you provide may be given to the federal government, and other public agencies to the extent required by law. Failure to provide this information will limit the DCSS’ ability to safeguard your information.

The agency official responsible for maintenance of the form is: DCSS Records Officer, PO Box 419064, MS-110, Rancho Cordova, CA 95741, fax number (916) 464-5069. Legal references authorizing solicitation and maintenance of this personal information include Title 22 California Code of Regulations §§112110(h), 112300, 112301, and 112302, as well as Family Code §17212. Copies of this form are maintained in confidential files of the Department of Child Support Services or local child support agencies for 4 years and 4 month after the closure of your child support case. You have the right of access to this form upon request by faxing (916) 464-5069.

If you have any questions or concerns regarding this notice, please call us at 1-866-901-3212.

Page 2 of 2

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