Exhibit CS0-1015A.pdf
PDF 147 KB Posted
- Attached to
- Master Agreement AZ|CTR071407
- Contract number
- CTR071407
- Issued by
- Arizona
About this file
This document is an Intake Medical Assessment form issued by the Arizona Department of Child Safety (DCS), specifically labeled as Exhibit CSO-1015A dated 02/24. The form is designed as a standardized tool for documenting physical observations, injuries, and markings during a child's intake process. The document includes fields for comprehensive child information and injury documentation, with body diagrams to precisely map and record any observed physical conditions.
The assessment form provides a structured method for recording medical observations, with checkboxes and body diagrams allowing staff to document various types of injuries or markings including burns, bruises, lacerations, fractures, bite marks, rashes, piercings, tattoos, scars, and birthmarks. The form includes options to indicate whether photographs of injuries were taken, and features multilingual accessibility information, emphasizing the department's commitment to equal opportunity and language assistance. The document is intended to be completed by staff members during the intake process, with one form to be used per child.
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Text version
INTAKE MEDICAL ASSESSMENT
ARIZONA DEPARTMENT OF CHILD SAFETYExhibit CSO-1015A
(02/24)
One Form Per Child
Child Information
Injury Information
Check those that apply and enter letter and number as appropriate on the child diagrams to show location of injury(ies) A: Burn G: Piercings
D: Fracture J: Scart
B: Bruise H: Tattoos
Right
Palm Palm
Top Top
Bottom Bottom
Front LeftBack
K: Other E: Bite Mark F: RashC: Laceration
I: Birthmarks
The following is a tool used to document any physical abuse, neglect or markings observed during the child’s intake
Child’s Name (Last, First, M.I.)
Staff Member’s Name
Birth Date Gender Ethnicity Date of Intake
Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics, or retaliation or any other status protected by federal law, state law, or regulation.
Reasonable accommodations to allow a person with a disability to take part in a program, service, or activity are available upon request. To request this document in alternative format or for further information about this policy contact your local office. TTY/TDD Services: 7-1-1. Free language assistance for DCS services is available upon request. Ayuda gratuita con traducciones relacionadas con los servicios del DCS esta disponible a solicitud del cliente.
Yes NoWere photographs of injuries taken?
| Text Field 1: |
| Text Field 18: |
| Text Field 2: |
| Text Field 3: |
| Text Field 4: |
| Text Field 5: |
| Check Box 6: Off |
| Check Box 12: Off |
| Check Box 9: Off |
| Check Box 15: Off |
| Check Box 7: Off |
| Check Box 13: Off |
| Check Box 16: Off |
| Check Box 10: Off |
| Check Box 11: Off |
| Check Box 8: Off |
| Check Box 14: Off |
| Radio Button 17: Off |
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