ࡱ>  @ ?sbjbj5*5* W@W@* &lllllll+++8zd}z4qHh ,----.6.$ /EGGGGGG$IR+LG]l0..00Gll--+H2220l-l-E20E22rd>Tlld?-{ Qe+0>@AH0qH>=M0=Md?llll=Mlr?!/>_/,2/$/!/!/!/GGd 2dCASEWORKER PERMANENCY PLANNING CHECKLIST(For Temporary Court Wards)State of MichiganDepartment of Human ServicesWhen reunification has been ruled out and there are specified reasons not to terminate parental rights, this form will assist the caseworker in determining if the childs current caregiver(s) would be appropriate for permanent guardianship. Complete a separate form for each child. The form must be signed by the caseworker and the caseworkers supervisor.Do not complete this form if adoption is the goal on the service plan.Child s NameBirthdateCaseworker s Name FORMTEXT       FORMTEXT       FORMTEXT      Child s SWSS Log NumberCaseworker s Title FORMTEXT       FORMTEXT      Caregiver NameChild Placing Agency FORMTEXT       FORMTEXT      Caregiver AddressDate Completed FORMTEXT       FORMTEXT      IMPORANT INFORMATION ABOUT GUARDIANSHIP ASSISTANCE. A child is eligible for guardianship assistance if:Child has resided with the caregiver for six or more consecutive months.Child demonstrates a strong attachment to the caregiver.Child 14 or older has been consulted about the guardianship.Child is under 18 years of age.Reunification and adoption as permanency goals have been ruled out.Permanent placement through guardianship is in the childs best interest.A caregiver who meets all of the following criteria is eligible to receive financial assistance.Child was placed in the caregivers home by the department as a foster care placement.The caregiver is a licensed foster parent.The child has resided in the caregivers home for six or more consecutive months.The caregiver has a strong commitment to caring permanently for the child.The caregiver and all adult household members have successfully completed Central Registry Clearance, a criminal history check and fingerprinting.The DHS-3310, Guardianship Assistance Certification/Agreement Request must be completed for all prospective guardianship cases, unless the guardian is not requesting financial assistance.COMPLETE THE FOLLOWING QUESTIONS.a. Reunification has been ruled out because: FORMTEXT      b. Termination has been ruled out because: FORMTEXT      YESNOc. The caseworker has documentation in the case file to support the response to questions a and b. FORMCHECKBOX  FORMCHECKBOX d. The caregiver demonstrates that he/she possesses the capability to assume the role of primary caregiver. FORMCHECKBOX  FORMCHECKBOX e. The caregiver demonstrates the capability to work cooperatively with the school and other agencies to address the childs academic and other needs. FORMCHECKBOX  FORMCHECKBOX f. The caregiver demonstrates the capacity to access appropriate medical care for the child. FORMCHECKBOX  FORMCHECKBOX g. The caregiver demonstrates the ability to manage birth parent or relative visitations so as to ensure that the child is not subject to harm or mistreatment. FORMCHECKBOX  FORMCHECKBOX h. The caregiver provides a safe and stable home environment that poses no dangers to the child. FORMCHECKBOX  FORMCHECKBOX i. The caregiver demonstrates the ability to manage family issues such as illness and child-rearing problems. FORMCHECKBOX  FORMCHECKBOX j. The caregiver demonstrates the ability to meet the special needs of the child or the child does not have special needs. FORMCHECKBOX  FORMCHECKBOX k. The child appears well integrated into the family. FORMCHECKBOX  FORMCHECKBOX PERMANENCY PLANNINGIf the caseworker answers yes to all of the preceding questions, permanent guardianship with assistance should be explored with the family. The caseworker should discuss the options with the caregiver using the Caregiver Permanency Planning Checklist and Making the Decision to Become a Childs Permanent Family (DHS-Pub-140). This discussion and the answers on the checklist will help the caseworker determine whether the caregiver is interested in pursuing guardianship for the children in their care. The Caregiver Permanency Planning Checklist is to be used as documentation of the planning process. It is also important to discuss current and planned living arrangements even with young children. If the child is 14 years or older, they must be consulted about permanent guardianship. The permanency goal should not be pursued for the child until the childs questions or issues have been addressed by the caseworker or through counseling. If there is a question about the youths decision, the caseworker should also schedule a separate meeting to discuss the permanency options with the child. A youth age 14 or older is required to sign the Youths Statement, located at the end of the Caregiver Permanency Planning Checklist. Caseworkers are encouraged to have all children of appropriate age involved in the discussion and allowed to sign the agreement. If any of the answers to the questions listed above are no and the caseworker does not believe that adoption or guardianship is appropriate, a conference should be held between the caseworker and supervisor to determined if it is in the childs best interest to remain in the current placement. 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The Caseworker Permanency Planning Checklist should be placed in the permanency planning section of the childs file.Workers SignatureDateSupervisors SignatureDateDepartment 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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Update other Form Fields on Form & Exit Macro- Selected$=GetFormResult$ ("CurrentDate")! TheSerialDate = Today() + 14$ TheDate$ = Date$(TheSerialDate)& SetFormResult "DueDate", TheDate$) EditGoTo "CreateDate" : UnlinkFields EditGoTo "GranteefirstName"- ToolsProtectDocument .NoReset = 1, .Type = 2/ ToolsProtectSection .Section = 2, .Protect = 0a FileClose 2 SelectName = - 1hplh`(Attribute VB_Name = "MyInfo" Public Sub Main(X) D.nDescription|Enter Personal rma:zProcDataIInvoke _FuncINoi8l..nADim iRet B  User$ATitleAreaCod-PhonYourExtFax|AC Offic $AddressCitByStat Zip ODILSEB;UN WKRBoss|| 'DEFINE DIALOG BOX WordBasic.BeginDialog 582, 300,} G TextBox 109@ A 5@ 18@ I @ey 56 * 83 _[ 105WDi 2A3321A5r 34 _  | 9 7 @ 1$55E [1 Pi 23` 6i`cV3jFAXAC41e lV1@,CO629 *DI7m pV? UN6z4!l1.yVm23n`~64`'Fz7,, c3z#the followin`g infa@bout ys0elf. ", ׂ !:w5f"bC #1z0@8O$351{1A-ST- u5 abm3r13@? gY  ;"C O-DI-T-U,N-@H47224*; supervisor!a 124f6p6iOKButtY48 8pR21 fCanctel3kEndn ҂dlg!u! 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ClientZipD ClientZip UppercaseKEnter the Addressee's Zip Code (+4 if known) (Example: 48909 or 48909-7537)D CoAddress UppercaseaEnter the County's mail address (street address, PO Box, etc., where the mail will be delivered).D CoAreaCodeEnter the County's Area CodeDCoCity UppercaseEnter the County's City.D CoExtensiond8(OJQJ_HmH sH tH XOX CaseNumber1?d8(OJQJ_HmH sH tH XOX ClientCity1@d8(OJQJ_HmH sH tH ZOZ ClientState1Ad8(OJQJ_HmH sH tH ZO"Z ClientZip1BdtCJOJQJ_HmH sH tH VO2V CoAddress1Cd8(OJQJ_HmH sH tH XOBX CoAreaCode1 Dd`CJOJQJ_HmH sH tH PORP CoCity1Ed8(OJQJ_HmH sH tH ZObZ CoExtension1Fd8(OJQJ_HmH sH tH ^Or^ CoPhoneNumber1Gd8(OJQJ_HmH sH tH ROR CoState1Hd8(OJQJ_HmH sH tH ^O^ CoSuppaddress1Id8(OJQJ_HmH sH tH XOX CountyName1Jd8(OJQJ_HmH sH tH \O\ CountyNumber1 Kd`CJOJQJ_HmH sH tH ROR CoZip1LdtCJOJQJ_HmH sH tH NON Date11 Md`CJOJQJ_HmH sH tH TOT District2 Nd`CJOJQJ_HmH sH tH LOL FaxAC Od`CJOJQJ_HmH sH tH VOV FirstName1Pd8(OJQJ_HmH sH tH XOX FirstName21Qd8(OJQJ_HmH sH tH `O"` GranteeAddress1 Rd`CJOJQJ_HmH sH tH \O2\ GranteeCareof Sd`CJOJQJ_HmH sH tH XOBX GranteeCity Td`CJOJQJ_HmH sH tH `OR` GranteeClientID Ud`CJOJQJ_HmH sH tH dObd GranteeFirstName2 Vd`CJOJQJ_HmH sH tH bOrb GranteeLastName1Wd8(OJQJ_HmH sH tH ZOZ GranteeState Xd`CJOJQJ_HmH sH tH VOV GranteeZip Yd`CJOJQJ_HmH sH tH TOT LastName1Zd8(OJQJ_HmH sH tH VOV LastName21[d8(OJQJ_HmH sH tH ROR OtherID1\d8(OJQJ_HmH sH tH ROR Section2 ]d`CJOJQJ_HmH sH tH ^O^ SuperAreaCode1 ^d`CJOJQJ_HmH sH tH `O` SuperExtension1_d8(OJQJ_HmH sH tH dOd SuperPhoneNumber1`d8(OJQJ_HmH sH tH `O` SupervisorName1ad8(OJQJ_HmH sH tH LO"L Unit2 bd`CJOJQJ_HmH sH tH PO2P Worker2 cd`CJOJQJ_HmH sH tH `OB` WorkerAreaCode1 dd`CJOJQJ_HmH sH tH bORb WorkerExtension1ed8(OJQJ_HmH sH tH TObT WorkerFax fd`CJOJQJ_HmH sH tH XOrX WorkerName1gd8(OJQJ_HmH sH tH \O\ WorkerName2hd8(5OJQJ_HmH sH tH ZOZ WorkerPhone1id8(OJQJ_HmH sH tH ^O^ WorkerTitle1jd8(5OJQJ_HmH sH tH LOL Emailkd8(OJQJ_HmH sH tH  }A0 0Address1BureauCareOf CaseNumber ClientCity ClientState ClientZip CoAddress CoAreaCodeCoCity CoExtension CoPhoneNumber CoState CoSuppaddress CountyName CountyNumberCoZipDate1DistrictEmail/FaxAC FirstName FirstName2GranteeAddress1 GranteeCareof GranteeCityGranteeClientIDGranteeFirstNameGranteeLastName GranteeState GranteeZipLastName LastName2OtherID Section! 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