ࡱ>   @ wbjbj5*5*  W@W@)Iggg8M L!hg>(m>m>m>mn\un<n T$Rۚ*5qnn5q5q*>m>mۖ+v+v+v5q4>m>mT+v5qT+v+vrh>mU ngiq(ڄ0$ 0!mq~m mtnh9oJ+vo<ovnnn**d1.9.v.9INITIAL RELATIVE SAFETY SCREENMichigan Department of Human ServicesRelative Caregiver(s) NameRelative Caregiver(s) Date of Birth FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Relative Caregiver(s) AddressRelative Caregiver(s) Phone: FORMTEXT       FORMTEXT      List all members of the householdName(s) FORMTEXT      DOB: FORMTEXT      Name of Child(ren) Placed in Relative Caregiver(s) Home:Case Number(s) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      SWSS Load # FORMTEXT       FORMTEXT      Worker NameDHS County or Private Child Placing Agency FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Central Registry CheckDate of Central Registry Check: FORMTEXT       FORMCHECKBOX No adult in the home is listed as a perpetrator on central registry. FORMCHECKBOX The following adult(s) in the home is listed as the perpetrator on central registry and placement cannot be made. FORMTEXT      State Criminal History Check*Date of criminal clearance: FORMTEXT       FORMCHECKBOX No member of the household has a felony conviction for one of the following crimes:Child abuse/neglect Spousal abuse Crime against children (including pornography).A crime involving violence, including rape, sexual assault or homicide but not including other physical assault or battery. A physical assault or battery within the last five years. A drug related offense within the last five years. FORMCHECKBOX The following member(s) of the household has a felony conviction for one of the offenses listed above and placement is prohibited.NameOffenseDate of Conviction FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX An adjudicated sex offender resides in the home and placement is prohibited. FORMCHECKBOX The relative caregiver(s) or other member of the household has a conviction that does not prohibit placement but requires further assessment.NameOffenseDate of Conviction FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Multiple CPS Investigations:Date of SWSS CPS clearance: FORMTEXT       FORMCHECKBOX No member(s) of the household has multiple CPS investigations wherein he/she is indicated as an alleged perpetrator in the home. FORMCHECKBOX The following adult(s) in the household has multiple CPS investigations and is indicated as the alleged perpetrator.Names:DOB: FORMTEXT       FORMTEXT      NOTE: Child safety must be assessed during contact with the relative considering this CPS information.  Safety of PlacementYesNo1. FORMCHECKBOX  FORMCHECKBOX Are there sufficient number of bedrooms & beds for all children needing placement including children residing in thehome?Number of bedrooms FORMTEXT      beds FORMTEXT      children FORMTEXT      .2. FORMCHECKBOX  FORMCHECKBOX The relative has a legal source of income to meet the familys needs.3. FORMCHECKBOX  FORMCHECKBOX The child(ren) has age appropriate supervision at all times even when the relative is absent from the home.4. FORMCHECKBOX  FORMCHECKBOX The relative agrees to follow the behavior management plan developed for each child by the agency (which includes refraining from the use of physical discipline).If No is checked in any of the above boxes, placement in prohibited.5. FORMCHECKBOX  FORMCHECKBOX Are all entrances/exits to and from the home unobstructed?6. FORMCHECKBOX  FORMCHECKBOX Is the home able to meet the childs health care needs? (e.g., Child has allergies to smoke and the household is smoke free, etc.)7. FORMCHECKBOX  FORMCHECKBOX Is the home free from observable health/sanitation risks?8. FORMCHECKBOX  FORMCHECKBOX Is the home free from observable safety hazards (e.g., Broken windows, exposed wires, etc.)?9. 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DB@d2 Name: DB@d 2 Title: DB@d X DB@J"X DB@L DB@N]XF D!R!T.P6GET USER INFO FROM INI FILE AND PUT IT INTO DIALOG BOXUserInfoName MYINFO.ini D%X P(VUserInfoTitle MYINFO.ini D%X P(ZUserInfoAreaCode MYINFO.ini D%X P("UserInfoPhone MYINFO.ini D%X P(\UserInfoYourExt MYINFO.ini D%X P(&UserInfoFaxAC MYINFO.ini D%X P((UserInfoFax MYINFO.ini D%X P(*UserInfoOffice MYINFO.ini D%X P(^UserInfoAddress MYINFO.ini D%X P(`UserInfoCity MYINFO.ini D%X P(bUserInfoState MYINFO.ini D%X P(dUserInfoZip MYINFO.ini D%X P(fUserInfoCO MYINFO.ini D%X P(hUserInfoDI MYINFO.ini D%X P(jUserInfoSEC MYINFO.ini D%X P(lUserInfoUN MYINFO.ini D%X P(nUserInfoWKR MYINFO.ini D%X P(pUserInfo Boss Name MYINFO.ini D%X P(@UserInfo Boss Title MYINFO.ini D%X P(B,DISPLAY DIALOG BOX AND RESPOND TO USER INPUT P D!r%T'  OK BUTTONWRITE NEW USER INFO IN INI FILEUserInfoName P!V MYINFO.ini DB@tUserInfoTitle P!Z MYINFO.ini DB@tUserInfoAreaCode P!" MYINFO.ini DB@tUserInfoPhone P!\ MYINFO.ini DB@tUserInfoYourExt P!& MYINFO.ini DB@tUserInfoFaxAC P!( MYINFO.ini DB@tUserInfoFax P!* MYINFO.ini DB@tUserInfoOffice P!^ MYINFO.ini DB@tUserInfoAddress P!` MYINFO.ini DB@tUserInfoCity P!b MYINFO.ini DB@tUserInfoState P!d MYINFO.ini DB@tUserInfoZip P!f MYINFO.ini DB@tUserInfoCO P!h MYINFO.ini DB@tUserInfoDI P!j MYINFO.ini DB@tUserInfoSEC P!l MYINFO.ini DB@tUserInfoUN P!n MYINFO.ini DB@tUserInfoWKR P!p MYINFO.ini DB@tUserInfo Boss Name P!@ MYINFO.ini DB@tUserInfo Boss Title P!B MYINFO.ini DB@tGet user info from INI fileUserInfoName MYINFO.ini D%X' UserInfoTitle MYINFO.ini D%X' UserInfoAreaCode MYINFO.ini D%X' "UserInfoPhone MYINFO.ini D%X' $UserInfoYourExt MYINFO.ini D%X' &UserInfoFaxAC MYINFO.ini D%X' (UserInfoFax MYINFO.ini D%X' *UserInfoOffice MYINFO.ini D%X' ,UserInfoAddress MYINFO.ini D%X' .UserInfoCity MYINFO.ini D%X' 0UserInfoState MYINFO.ini D%X' 2UserInfoZip MYINFO.ini D%X' 4UserInfoCO MYINFO.ini D%X' 6UserInfoDI MYINFO.ini D%X' 8UserInfoSEC MYINFO.ini D%X' :UserInfoUN MYINFO.ini D%X' <UserInfoWKR MYINFO.ini D%X' >UserInfo Boss Name MYINFO.ini D%X' @UserInfo Boss Title MYINFO.ini D%X' B Update Form with user info WorkerName D%vG workerName  DB@xj WorkerTitle D%vG WorkerTitle  DB@xjWorkerAreaCode D%vGWorkerAreaCode " DB@xj WorkerPhone D%vG WorkerPhone $ DB@xjWorkerExtension D%vGWorkerExtension & DB@xjFaxAC D%vGFaxAC ( DB@xj WorkerFax D%vG WorkerFax * DB@xj Countynumber D%vG Countynumber 6 DB@xjDistrict D%vGDIstrict 8 DB@xjSection D%vGSECtion : DB@xjUnit D%vGUNit < DB@xjWorker D%vGWorker > DB@xj CountyName D%vG CountyName , DB@xj CoAddress D%vG CoAddress . 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