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Form 453 cps intake referral
- 1. Form 453 -Intake Worksheet Report Date of Report Time AM PM Case Name County # Case # Address Telephone # Work # Work # Directions to Home Screening for History Sources Screened Date Checked Yes No Comments Screen Print? County Card Files Yes No IDSOnline Yes No PSDS Yes No IDS Yes No Sexual Offender Registry Yes No DOC Offender Query Yes No Probation/Parole Yes No SUCCESS Yes No GHP PORTAL _____ □ □ _____ Yes □ No □ Date referred to Law Enforcement Jurisdiction Family Information Caretaker - Name Birth Date Age Relationship Maltreater Sex Race Ethnicity SSN Children Name Birth Date Age Sex Race Ethnicity SS# AM Code Child’s Location Maltreater Alleged Maltreater ( if not designated above) Relationship to Victims Address City State ZIP Telephone Birth Date Age Sex Race Ethnicity Form 453 Intake Worksheet (Rev. 11-03) Page 1 of 2
- 2. Reporter’s Allegations Comments (Othersources of information – include other potential witnesses and collaterals to contact) Disposition Intake Worker Worker # Telephone # Supervisor Date Accept/Assign 24 Hour* Five Day * Add to pending/open case* Screen Out Screen Out Reason Screen Out and refer - Screen Out Reason and Referral Resource: Reason Date/Time referred Referral Made to *Assignment Information (to be completed by Investigations supervisor) Assigned Case Manager Date Assigned Time AM PM Supervisor Reporter Information Name Relationship to Children Address Home Telephone Number Work Telephone Number Confidentiality Explained Yes No Mandated Reporter Yes No Date Mandated Reporter Letter Sent Form 453 Intake Worksheet (Rev. 11-03) Page 2 of 2