Click here to view, print, or complete the CP&P Form 11-3, Pre-Placement/Re-Placement Assessment, on-line.

Instructions 8-13-2007

PURPOSE AND USE

The purposes served by this form include:

·         Document a child's pre-placement or re-placement health assessment

·         Document a child's health and medical history for the resource parent/residential placement

·         Determine if the child has a disability that requires special transportation

·         Use as evidence in child abuse litigation

Attach the completed CP&P Form 11-3 to CP&P Form 11-63, Request for CHEC Visit.

INSTRUCTIONS FOR COMPLETING THE FORM

The Worker completes the first section of the form on-line or by pen and ink and provides the form to the health care professional for completion at the time of the assessment, to document the assessment.

Note:  Local Office nurses have the form.  When conducting the health assessment, they complete and forward the entire form electronically.  Other health professionals complete the form by hand, using pen and ink.

DISTRIBUTION

Original          -           Child's case record

Copy               -           Caregiver

Copy               -           Health care professional/LO nurse