Report Of Childs Injuries Pursuant To WIC Section 317 Subdivision(e) {JUV041} | Pdf Fpdf Docx | California

 California /  Local County /  Los Angeles /  Juvenile /
Report Of Childs Injuries Pursuant To WIC Section 317 Subdivision(e) {JUV041} | Pdf Fpdf Docx | California

Report Of Childs Injuries Pursuant To WIC Section 317 Subdivision(e) {JUV041}

This is a California form that can be used for Juvenile within Local County, Los Angeles.

Alternate TextLast updated: 10/24/2018

Included Formats to Download
$ 17.99

Description

Superior Court of California County of Los Angeles APPENDIX 1 REPORT OF CHILD222S INJURIES PURSUANT TO WELFARE AND INSTITUTIONS CODE SECTION 317, SUBDIVISION (e) DEPENDENCY ATTORNEY NAME: OFFICE ADDRESS: OFFICE TELEPHONE: OFFICE FAX: ASSIGNED COURT: COURT TELEPHONE: ATTORNEY FOR: SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES JUVENILE DEPENDENCY COURT IN THE MATTER OF ) COURT DEPARTMENT: ) ) ) CHILD222S CASE NUMBER: ) ) ) NEXT COURT DATE: ) ) REPORT OF CHILD222S INJURIES ) PURSUANT TO WELFARE AND ) INSTITUTIONS CODE A CHILD ) SECTION 317, SUBDIVISION (e) ) A preliminary investigation regarding the above-captioned child is complete and dependency counsel submits this report to the court pursuant to Welfare and Institutions Code section 317(e) for a court determination as to whether further action should be commenced. If the court refers this matter to outside counsel, such counsel is advised to independently investigate the information contained in this report as it is based solely on documents and information available at this time. American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Los Angeles 1.CHILD222S INFORMATIONH)NAME:I)DATE OF BIRTH:J)CHILD222S SOCIAL SECURITY NUMBER:K)CHILD222S MEDI-CAL NUMBER:L)CHILD222S DRIVER222S LICENSE NUMBER, IF APPLICABLE:M)CHILD222S LANGUAGE:2.CHILD222S CONTACT INFORMATIONA)CURRENT RESIDENCE:B)TELEPHONE NUMBER:C)CARETAKER222S NAME AND RELATIONSHIP TO CHILD:D)NAME AND LOCATION OF CHILD222S CURRENT SCHOOL:E)NAME AND TELEPHONE NUMBER OF CHILD222S CSW ANDCSW222S SUPERVISOR:F)NAME OF CHILD222S CASA:3.CHILD222S BACKGROUND INFORMATIONA)WHY IS THE CHILD UNDER THE JURISDICTION OF THE COURT?B)MOTHER222S NAME, ADDRESS AND TELEPHONE:C)FATHER222S NAME, ADDRESS AND TELEPHONE:D)REGIONAL CENTER CLIENT? YES NO i.NAME OF REGIONAL CENTER:ii.CLIENT IDENTIFICATION NUMBER:E)SPECIAL EDUCATION STUDENT? YES NO i.REASON FOR CLASSIFICATION: American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Los Angeles ii.DATE OF LAST IEP MEETING:F)MENTAL HEALTH ISSUES:G)PREEXISTING MEDICAL CONDITIONS:4.INCIDENT INFORMATIONA)DATE(S) OF INCIDENT(S):B)DATE(S) AND MANNER CHILD222S DEPENDENCY ATTORNEY RECEIVEDNOTIFICATION OF CHILD222S INJURY:DATE:MANNER:C)PHYSICAL LOCATION WHERE INCIDENT OCCURRED:D)DETAILED DESCRIPTION OF INCIDENT(S) (ATTACH A SEPARATE SHEETIF NECESSARY):E)LAW ENFORCEMENT AGENCY REPORT NUMBER:5.DAMAGESA)INJURIES SUSTAINED (INCLUDE AS MUCH INFORMATIONAS POSSIBLE):B)MEDICAL TREATMENT REQUIRED/RECEIVED (PLEASE INCLUDE NAMES,ADDRESSES OF PROVIDER(S), AND CHILD222S PATIENT IDENTIFICATIONNUMBER, IF KNOWN):6.LIABILITYA)NAME, ADDRESS AND TELEPHONE OF CHILD222S RESIDENCE AT THE TIMEOF INJURY:B)NATURE OF CHILD222S RESIDENCE AT TIME OF INCIDENT (CHECK ALLTHAT APPLY): American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Los Angeles HOME OF PARENT(S) HOME OF GUARDIAN(S) HOME OF RELATIVE(S) FOSTER CARE HOME FOSTER FAMILY AGENCY NAME: GROUP HOME OTHER C)NAMES OF POTENTIAL DEFENDANT(S), IF KNOWN, AND DESCRIPTIONOF INVOLVEMENT IN INCIDENT:D)NAMES OF OTHER POTENTIAL PLAINTIFFS, IF KNOWN (INCLUDING KNOWNSIBLINGS) AND DESCRIBE RELATIONSHIP TO CHILD:E)NAME OF SIBLING'S DEPENDENCY ATTORNEY, IF KNOWN (INCLUDINGCONTACT INFORMATION):F)NAMES, ADDRESSES AND TELEPHONE NUMBERS OF WITNESSES AND/OROTHER SUPPORTING CONTACTS:7.ADDITIONAL INFORMATIONPLEASE IDENTIFY (AND ATTACH IF POSSIBLE) ANY SUPPORTING DOCUMENTATION THAT YOU EITHER POSSESS OR WHICH YOU KNOW EXISTS. This report is complete to the best of my knowledge at the time of filing. If I receive any further information or documents prior to notification that a tort attorney has accepted this case, I will file them as a supplement to this report with the office of the Presiding Judge as soon as possible. DATED: Respectfully submitted, By: Dependency Court Attorney for Child American LegalNet, Inc. www.FormsWorkFlow.com

Our Products