Out-Of-Home Placement Or Recommended Placement Notification, CFS-2189

OUT-OF-HOME PLACEMENT OR RECOMMENDED PLACEMENT NOTIFICATION

Use of form: Pursuant to ss. 48.64(1r) and 115.81(3), Stats. this form is to be used when an agency, as defined in s. 48.64(1), Stats. is required to notify the school and the school district that the agency placed a school aged child in out-of-home care in the school district the child has been placed and the school in which the child will enroll after the placement is made, unless the child will remain enrolled in his or her school and school district of origin. If the child will remain enrolled in his or her school and school district of origin, the agency shall provide notification to the school and school district of origin. In addition, agencies are required to notify the school district in which a child resides prior to placement in a Residential Care Center (RCC) whenever the agency recommends to a court that a child be placed in an RCC. Use of this form is voluntary; however, the information must be provided. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes].

DATE: / Month DD, YYYY[TM1]
TO: / [TM2] School District
[TM3]
[TM4] School
[TM5]
FROM: / [TM6], [TM7]
[TM8]

RE:Notification of the Placement of a Child in Out-of-Home Care or

Recommended Placement of a Child in a Residential CareCenter.

[TM9] / This is to notify you, pursuant to s. 48.64(1r), Stats., that a child has been placed in the [TM10]Group HomeFoster HomeTreatment Foster Home[TM11] in your school district in the citytownvillage[TM12] of [TM13]. The effective date of the child’s placement iswas[TM14][TM15].
NOTE: Send form to the school and school district in which the out-of-home care provider is located.
[TM16] / This is to notify you, pursuant to s. 115.81(3), Stats., that a recommendation has been made to the juvenile court that a child be placed in the [TM17] Residential Care Center located in the citytownvillage[TM18] of [TM19]. The date of recommendation to the court iswas[TM20][TM21].
NOTE: Send form to school district in which the child is / was residing at the time of the recommendation to the court.
[TM22] / This is to notify you, pursuant to s.115.81(3), Stats., that a child has been placed in the [TM23]ResidentialCareCenter located in the citytownvillage[TM24] of [TM25]. The effective date of the child’s placement is [TM26].
NOTE: Send form to school district in which the child was residing prior to placement in the Residential Care Center.

The following information relates to that child:

Name: [TM27] / Age: [TM28] / Gender: [TM29]
CurrentPrevious[TM30]School: [TM31] / CityTownVillage[TM32]:[TM33] / State: [TM34]

Contact me at the following address or telephone number if you have questions regarding this child or the placement.

[TM35]

[TM36]

Copy: Group Home or Residential CareCenter Administrator / Foster Parent / Treatment Foster Parent

Out-Of-Home Placement Or Recommended Placement Notification / Page 2 of 2
CFS-2189 (Rev. 07/2018)

[TM1]This field is pre-filledwith the current date. Not editable on the template.

[TM2]This field is pre-filled with the most recent record in the School District of Jurisdiction field on the Education window, School District Jurisdiction History group-box. Not editable on the template. The information can be changed on the Education window, School District Jurisdiction History group-box.

[TM3]This field is pre-filled from the District Address field on the Education Notification page, but is editable on the template.

[TM4]This field is pre-filled from the School Name field on the Education Notification page, but is editable on the template.

[TM5]This field is pre-filled from the School Address field on the Education Notification page, but is editable on the template.

[TM6]This field is pre-filled with the name of the worker who is creating the document. Not editable on the template. The name detail can be changed on the worker's Person Management window, Name box, First/Last Name fields.

[TM7]This field is pre-filled with the title of the worker who is creating the document. Not editable on the template. The worker's title can be changed on the Worker Information window, Current Position Information group-box, Job Class field.

[TM8]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM9]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM10]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM11]1This field is user-selected. The values are:[Foster Home] [Group Home] [Shelter Care Facility] [Residential Care Center] [Relative, other than a parent]

[Unlicensed, non-relative].

[TM12].This field is user-selected. The values are: [city] [town] [village].

[TM13]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM14]1This field is user-selected. The values are: [is] [was].

[TM15]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM16]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM17]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM18]This field is a user selectable dropdown withthe following available choices: [city] [town] [village]

[TM19]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM20]1 This field is user-selected. The values are: [is] [was].

[TM21]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM22]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM23]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM24]This field is user-selected. The values are: [city] [town] [village].

[TM25]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM26]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM27]This field is pre-filled with the name of the child for whom the Education window was launched. Not editable on the template. This detail can be changed on the Person Management window, Basic tab, Name group-box.

[TM28]This field is pre-filled from the Person Management window, Basic tab, Basic group-box (calculated based on the date of birth entered in the Birth Date field). Not editable on the template. This detail can be changed in the Person Management window, Basic tab, Basic group-box, Birth Date field.

[TM29]This field is pre-filled with the gender of the child entered in the Gender field of the Basic tab, Person Management window. Not editable on the template. This detail can be changed in the Gender field of the Basic tab, Person Management window.

[TM30]1This field is user-selected. The values are: [current] [previous].

[TM31]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM32]This field is user-selected. The values are: [city] [town] [village].

[TM33]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM34]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM35]This field is user-entered. This field is editable on the template. The data can be corrected on the template.

[TM36]This field is pre-filled with the worker's telephone number. Not editable on the template. This detail can be changed on the Maintain Worker Information window.