Attachment D.pdf
PDF 182 KB Posted
- Attached to
- TRANSPORTATION SERVICES - DSS
- Solicitation number
- 5400028028
- Issued by
- Richland County, South Carolina
About this file
This document is an Emergency Placement Transportation Request Form from the South Carolina Department of Social Services (DSS), designed to facilitate the transportation of youth in foster care or emergency placement situations. The form provides comprehensive details for coordinating transportation, including pick-up and drop-off location specifics, contact information, special transportation requirements, and critical logistical considerations such as car seat needs, driver assistant requirements, and wait times.
The form includes extensive sections for documenting the youth's specific needs, behavioral considerations, and logistical preparations, such as medication transportation, clothing and personal belongings, dinner arrangements, and electronic device protocols. The document covers multiple regional placement units across South Carolina (Upstate, Midlands, Low Country, and Pee Dee), with on-call phone numbers for each region. The final section is reserved for internal DSS placement staff to document transportation agency details, mileage calculations, driver information, and approval documentation.
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Other files
| File | Type | Posted |
|---|---|---|
| Amendment 1 5400028028.docx | DOCX document | |
| Attachment C.docx | DOCX document | |
| Attachment E.docx | DOCX document | |
| Attachment F.pdf | ||
| Attachment G.pdf | ||
| Attachment H.pdf | ||
| Solicitation 5400028028.docx | DOCX document |
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Text version
DSS Form 37706 (JUL 24) Page 1 of 4
EMERGENCY PLACEMENT TRANSPORTATION REQUEST FORM
Client Name Date of Birth Case ID Number
Client Age List Names of All Sibling(s) or Other Foster Child(ren) Being Transported
Client Gender
Case Manager Name Case Manager Mobile Number
County DSS Office and Region County Hot Phone Number
Placement Unit On-Call Phone Number Upstate Placement Unit on-call - 864-642-8432 Midlands Placement Unit on-call - 803-605-0145 Low Country Placement Unit on-call - 843-371-9421 Pee Dee Placement Unit on-call - 843-616-2004
Pick Up Details Location Name Date Time
Address Description (i.e., DSS office, etc.)
Pick Up Contact Name Pick Up Contact Phone
Drop Off Details Drop Off Location Name Estimated Time of Drop Off
Address Description (i.e., foster home, group home, etc.)
Drop Off Contact Name Drop Off Contact Phone
Driver Assistant Needed? Yes No If yes, explain why a driver assistant is needed.
Is Wait Time Needed? Yes No If yes, how long will the wait time be?
Is Car Seat Required? Yes No If yes, select type needed: Rear Facing Forward Facing Belt Positioning Booster
Person ID Number
DSS Form 37706 (JUL 24) Page 2 of 4
Description of Client’s Behaviors/Needs/Risk Factors
Comments or Special Concerns
Description of Youth’s Belongings Being Transported with Client (i.e., medications with instructions, youth personal items, etc.)
Are medications coming with the youth? If so, please list the medications. (**Please hand all medications directly to the transporter**)
Are clothing and any other belongings that the youth needs for the evening or next morning with them at their physical location of pick up? If not, what is the plan for how the youth will receive their clothing and belongings for the evening and next morning?
What is the child’s plan for dinner? (i.e., county providing dinner prior to transport, county providing food gift card, bag dinner from the activity center, case manager feeding youth prior to transport, confirmation that the overnight provider will be feeding the youth, etc.)
DSS Form 37706 (JUL 24) Page 3 of 4
If the morning drop-off location is anywhere other than the County DSS (i.e., school, activity center, etc.), are the youth’s belongings able to remain with them or do they need to go to a separate location?
If they must be taken to a separate location, where should the transporter take their belongings and who is their contact and phone number who will receive their belongings?
Has the youth been made aware of where they are going for emergency placement? Are they in agreement to going to the identified overnight placement or are there concerns the youth will refuse placement?
If the youth is going to a group home, has any necessary intake paperwork that was sent in the placement notification email been completed and returned to the provider?
If the youth’s identified emergency placement does not allow for cell phones or other electronics, has the youth provided these to DSS to keep at the office? (**transportation cannot be arranged for a youth if they have not yet handed over their electronics to DSS**)
If a youth is being transported to Sea Haven, has a conversation been conducted with the youth regarding Sea Haven’s rules for electronics and are they willing to cooperate? Please refer to Sea Haven’s intake packet for details.
DSS Form 37706 (JUL 24) Page 4 of 4
***PLEASE DO NOT ENTER INFORMATION IN THIS SECTION***
(For Placement Staff Only)
Transportation Agency Name Transport/Mileage Confirmed By (Transport Agency Representative)
Placement Team Member Who Approved EP Transport (signature, title, and date)
Driver Name Driver Contact
Driver Home Base Address (Point A)
Youth Pick Up Address (Point B) Total Mileage from A to B
Youth Drop Off Address (Point C) Total Mileage from B to C
Driver Home Base Destination (Point D) Total Mileage from C to D
Total Mileage Roundtrip (A+B+C+D) Total Mileage Cost Total Wait Time Total Wait Time Cost
Reason for Approval
| Client Name: |
| Date of Birth: |
| Case ID Number: |
| Client Age: |
| Client Gender: |
| List Names of All Siblings or Other Foster Children Being Transported: |
| Case Manager Name: |
| Case Manager Mobile Number: |
| County DSS Office and Region: |
| County Hot Phone Number: |
| Location Name: |
| Date: |
| Time: |
| Address: |
| Description ie DSS office etc: |
| Pick Up Contact Name: |
| Pick Up Contact Phone: |
| Drop Off Location Name: |
| Estimated Time of Drop Off: |
| Address_2: |
| Description ie foster home group home etc: |
| Drop Off Contact Name: |
| Drop Off Contact Phone: |
| Driver Assistant Needed Yes No If yes explain why a driver assistant is needed: |
| Is Wait Time Needed Yes No If yes how long will the wait time be: |
| Description of Clients BehaviorsNeedsRisk Factors: |
| Comments or Special Concerns: |
| Description of Youths Belongings Being Transported with Client ie medications with instructions youth personal items etc: |
| Are medications coming with the youth If so please list the medications Please hand all medications directly to the transporter: |
| Are clothing and any other belongings that the youth needs for the evening or next morning with them at their physical location of pick up If not what is the plan for how the youth will receive their clothing and belongings for the evening and next morning: |
| What is the childs plan for dinner ie county providing dinner prior to transport county providing food gift card bag dinner from the activity center case manager feeding youth prior to transport confirmation that the overnight provider will be feeding the youth etc: |
| If the morning dropoff location is anywhere other than the County DSS ie school activity center etc are the youths belongings able to remain with them or do they need to go to a separate location If they must be taken to a separate location where should the transporter take their belongings and who is their contact and phone number who will receive their belongings: |
| Has the youth been made aware of where they are going for emergency placement Are they in agreement to going to the identified overnight placement or are there concerns the youth will refuse placement: |
| If the youth is going to a group home has any necessary intake paperwork that was sent in the placement notification email been completed and returned to the provider: |
| If the youths identified emergency placement does not allow for cell phones or other electronics has the youth provided these to DSS to keep at the office transportation cannot be arranged for a youth if they have not yet handed over their electronics to DSS: |
| If a youth is being transported to Sea Haven has a conversation been conducted with the youth regarding Sea Havens rules for electronics and are they willing to cooperate Please refer to Sea Havens intake packet for details: |
| Transportation Agency Name: |
| TransportMileage Confirmed By Transport Agency Representative: |
| Placement Team Member Who Approved EP Transport signature title and date: |
| Driver Name: |
| Driver Contact: |
| Driver Home Base Address Point A: |
| Youth Pick Up Address Point B: |
| Total Mileage from A to B: |
| Youth Drop Off Address Point C: |
| Total Mileage from B to C: |
| Driver Home Base Destination Point D: |
| Total Mileage from C to D: |
| Total Mileage Roundtrip ABCD: |
| Total Mileage Cost: |
| Total Wait Time: |
| Total Wait Time Cost: |
| Reason for Approval: |
| Group1: Off |
| Group2: Off |
| Group3: Off |
| Group4: Off |
| Group5: Off |
| Text1: |
File details come from the government source that posted it. Updated .