Form Cfs 428 PDF Details

The CFS 428 form serves a vital role for the State of Illinois Department of Children and Family Services, acting as an essential document in recording detailed information about a child under their care or supervision. This exhaustive form, last revised in April 2001, encapsulates crucial data ranging from the basic—such as the child's name, birthdate, and sex—to the intricacies of care requirements and emergency contacts. It includes sections for parent or guardian details, alternative emergency contacts, and the designated physician for cases of illness or injury, ensuring a comprehensive caretaking blueprint is always accessible. Importantly, it goes beyond mere identification to include the child's medical issues, physical limitations, dietary needs, allergies, and even specific personal preferences and routines which are central to providing tailored and conscientious care. This form is mandated to be filled out thoroughly by anyone placing a child in care and retained by the licensee, making it available for review by licensing representatives from the Department of Children and Family Services. It underscores an overarching commitment to child welfare, aiming to safeguard the well-being and personal needs of every child it concerns, while maintaining the confidentiality of the sensitive information it holds.

QuestionAnswer
Form NameForm Cfs 428
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesOintment, licensee, caregiver, dislikes

Form Preview Example

CFS 428

 

 

State of Illinois

 

 

 

Department of Children and Family Services

 

 

Rev. 4/2001

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICATION/RECORD OF CHILD INFORMATION

 

 

 

Name of Child

 

 

 

 

 

 

 

 

 

 

Birthdate

 

Sex

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Child Received

 

 

 

 

 

 

 

 

 

 

Date Child Left

 

 

 

 

PARENT OR OTHER PERSONS(S) PLACING THE CHILD

 

 

 

Name

 

 

 

 

 

 

 

Name

 

 

 

 

Relation to child

 

 

 

 

 

 

 

Relation to child

 

 

 

 

Home address

 

 

 

 

 

 

Home address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

Phone Number

 

 

 

 

Place of employment

 

 

 

 

 

 

Place of employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

Address

 

 

 

 

Phone Number

 

 

 

 

 

 

 

Phone Number

 

 

 

 

Working hours

 

 

 

 

 

 

 

Working hours

 

 

 

 

OTHER PERSON TO NOTIFY IF PERSON PLACING THE CHILD CANNOT BE REACHED

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

Phone Number

 

 

 

 

 

 

 

Relationship

 

 

 

 

PHYSICIAN TO CALL IF CHILD BECOMES ILL OR INJURED

 

 

 

Name

 

 

 

 

 

 

 

Address

 

 

 

 

Phone Number

 

 

 

 

 

 

 

Hospital or Clinic

 

 

 

 

PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Days per week

 

 

 

 

 

 

 

Hours of care

 

 

 

 

Rate of pay (optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of parent or other person placing child

 

 

 

 

Signature of caregiver

Date

A completely filled in form must be kept by the licensee for each child not related to the licensee. Please have this form available at all times to licensing representatives of the Department of Children and Family Services. Contact the Area Office for supplies of this form.

If the child has any of the following, please explaining:

Medical problems

Physical handicaps

Restrictions for play—outdoors

Restrictions for play—indoors

Allergies

Food likes

Food dislikes

Fears

Does the child take a nap?

 

 

Time

 

 

Length

 

Is the child toilet trained?

 

 

 

 

 

 

 

 

 

 

 

 

Does the child have special names for objects? (potty, cookies, drinks, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the child regularly take medication?

 

 

If so, what kind and directions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the child is an infant, what are the feeding instructions?

 

 

 

 

 

 

 

 

 

 

 

Time

 

 

 

 

 

Amount

 

 

 

 

 

 

Temperature

 

 

Diaper changes:

Powder

 

 

 

 

Ointment

 

 

 

Other information that will help in caring for the child

Comments:

ALL INFORMATION SHALL BE REGARDED AND HANDLED CONFIDENTIALLY

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Completing this form needs care for details. Make sure each blank field is completed properly.

1. The optional will require certain details to be inserted. Be sure the subsequent blank fields are completed:

Filling in segment 1 of handicaps

2. The subsequent step is usually to complete the next few blanks: Phone Number, Working hours, Phone Number, Working hours, OTHER PERSON TO NOTIFY IF PERSON, Name, Phone Number, Address, Relationship, PHYSICIAN TO CALL IF CHILD BECOMES, Name, Phone Number, PROGRAM, Days per week, and Rate of pay optional.

handicaps writing process explained (step 2)

Always be extremely careful while filling in Rate of pay optional and Phone Number, because this is where many people make some mistakes.

3. In this stage, examine Signature of parent or other, A completely filled in form must, Signature of caregiver, and Date. Each of these must be completed with highest precision.

Part number 3 for submitting handicaps

4. It is time to begin working on this fourth part! In this case you will get these If the child has any of the, Medical problems, Physical handicaps, Restrictions for playoutdoors, Restrictions for playindoors, Allergies, Food likes, and Food dislikes form blanks to do.

handicaps conclusion process shown (stage 4)

5. When you draw near to the last sections of this form, you'll notice several more things to complete. Particularly, Fears, Does the child take a nap, Is the child toilet trained, Time, Length, Does the child have special names, Does the child regularly take, If so what kind and directions, If the child is an infant what are, Time, Amount, Temperature, Diaper changes, Powder, and Ointment must be filled out.

Does the child have special names, Does the child take a nap, and Amount of handicaps

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