ESBD_File_267623_ESBD_File_267623_HHS0011287_Form 3116 and Referral Form_Package_2.pdf

Procurement HHS0011287 January 2022

DFPS REFERRAL FOR SUPPLEMENTAL CAREGIVER SERVICES

Purpose: The purpose of this form is for the Contractor selected to provide Supplement Caregiver Services for children and youth to document completion of required tasks as well as document arrival/departure times for the purposes of billing.

Directions: The Supplemental Caregiver for the Supplemental Caregiver Services must print this document and bring it with them to the supervision site. The Supplemental Caregiver completes this form at the supervision site. All Sections are completed by the Supplemental Caregiver. In addition, Sections III and VI must be signed by the Contractor Supplemental Caregiver and the DFPS On-Site Lead at the supervision site. This completed form must be attached to all billing invoices for payment. Non-emergency concerns can be reported to DFPSCWOPContracts@dfps.texas.gov which is monitored during business hours. T

SECTION I. CPS CONTACT INFORMATION

CPS On-Site Lead: Cell Phone:

CPS On Site Caseworker’s Email: Emergency Phone Number:

Location of the DFPS Supervision:

Note: Contractor will not be responsible for arranging transportation and must not provide transportation to any child or youth.

SECTION II. SIGN IN LOG

All Contractor Staff Supervising Children Must Show a Valid Identification Document (ID) (i.e. Driver's License of ID Card. The form also requires the signature(s) of the DFPS Shift Lead on duty providing rules, instructions and key information. Note: Contractor Observer is required to arrive 15 minutes prior to scheduled shift for debriefing. This Form is required to be submitted with the Contractor’s monthly billing for supervision services.

Date: Time of Arrival at the DFPS Approved Location (include AM or PM):

Contractor Name: Contractor Agency ID#:

Supplemental Caregiver(s) Full Name(s): DFPS Shift Lead or DFPS Designee Name:

mailto:DFPSCWOPContracts@dfps.texas.gov

Procurement HHS0011287 January 2022

SECTION II. AFFIRMATIONS

DFPS Supervision Services Rules and/or Procedures Reviewed with Shift Lead:

Yes No

Sexual History Report - Attachment A Reviewed and 2279b was signed by Contractor staff:

Yes No

Debriefed on previous shift:

Yes No

Contractor Staff Signature:

X DFPS Shift Lead Signature:

X

SECTION III. SUPERVISION CHANGE

This section is completed by the Contractor staff when the DFPS Supervision is Cancelled, Incomplete, or Delayed.

Reason for Schedule Change:

Cancelled by DFPS Incomplete Delayed Cancelled by Contractor N/A

Explain the reason the shift was not completed:

Explain how and when the DFPS Caseworker was notified of the Contractor cancelled supervision:

SECTION IV. SIGNATURES

This section is completed by the Contractor Observer to document any comments related to the DFPS Supervision.

If more space is needed, please attach additional documents.

Time of Departure at the DFPS Approved Location (include AM or PM): REQUIRED FOR PAYMENT OF

SERVICES RENDERED

Contractor Staff Signature:

X DFPS Shift Lead Signature:

X

4900 North Lamar Blvd • P.O. Box 149030 • Austin, Texas 78714-9030 • 512-929-6900 • www.dfps.state.tx.us An Equal Opportunity Employer and Provider

Commissioner Jaime Masters

Texas Department of Family and Protective Services

To:

From:

Subject:

All Child Watch Support Coordinators Erica Banuelos, CPS Associate Commissioner Children Under DFPS Supervision

Our core mission is to ensure child safety, and this obviously includes ensuring child safety when we have a child under DFPS care and supervision in another alternative location.

When you are serving in the role of providing supervision to a child in need of placement, it is imperative that they have your undivided and full attention. This means no multi-tasking while you are responsible for providing supervision to a child or youth in care.

The required service expectations are as follows:

• The direct service provider will obtain information about the child or youth's individual needs and relevant history from DFPS Lead staff prior to providing direct supervision services to the child, youth, or group. This includes information about the child's history of sexual abuse or sexual aggression, as well any history of human trafficking.

• For each child, the direct service provider will review the Attachment A – Sexual History Report and sign Form 2279b (Certification of receipt of child sexual abuse or sexual aggression information) for the child or youth, after the information is provided by DFPS Shift Lead or DFPS designee.

• All children and youth must remain in close proximity to CPS or CPI Staff and other trained adult caregivers at all times. The following factors should be considered when determining the type of supervision to be implemented for each child: normalcy for the child, child's service/treatment plan, and best interests of the child.

• The direct service provider will make reasonable efforts to meet the individual needs of the child or youth and interact with them as appropriate with consideration for their intellectual functioning, literacy, level of education, and comprehension ability with approval from DFPS Shift Lead or DFPS designee. At no point should direct service provider give a child or youth their cell phone or allow the child or youth to use their personal hotspot.

• If a significant event or issue arises during your shift while supervising a child or youth, you shall notify the DFPS Shift Lead or designee immediately.

By following these expectations and DFPS Policy, we can ensure that children and youth under our supervision remain protected and safe.

Print, sign, date, and submit this document for each proposed direct service provider along with your amendment or application package. This document must be reviewed and signed by all direct service providers prior to providing DFPS Supervision Services.

DFPS Contractor Observer Name Signature Date https://www.dfps.state.tx.us/handbooks/CPS/Files/CPS_pg_4000.asp#CPS_4152_2