This form (by SusieQ) is to be used by third parties (not either parent) when documenting a DFACS/DSS visit or attempted visit to a home. This sheet to be filled out by neighbor, bystander, or witness (designated third party) to any visitation by Child Protective Services to a family. Use honest answers blended with common sense of normal family living: ------------------------------------------------------------------ Independent On-Call Evaluator Form =================================================================== Your name:________________________ Friend- Family-Neigbor-Lawyer-paralegal-advocate; of family visited (circle one) Phone number:__________________________ Date:________ Full name and ages of parents and children's home visited by child welfare agents: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Circle answers-make comments if you wish 1. Demeaner of CPS agent upon your arrival: a. Cynical b. Asked you to leave (although you have every right to stay) c. Upset by your arrival d. Ambevelent e. Friendly and respectful f. Open to your presence and is cooperative comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 2. Demeaner of Parent under scrutinty (most of the following normal responses): a. frightened, nervous, insecure; unsure how to act b. fearful, feels they to have nothing to hide c. friendly to agent but firm on specific issues of visit d. Not at all happy with visit, addresses need for court order or parental rights, but allows entry. e. Firmly refuses CPS agents entry without required search warrant or court order. comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 3. Appearance of children (if present): a. appear happy, but confused by strangers (CPS agent/police officer) presence. b. shy or fearful of the strangers (perhaps clings to safety of parent) c. happy and open with strangers d. crying out for help from strangers to rescue them from horrifying abuse (kids under 8). Clinging to safety of CPS agent/officer present. comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4. Physical appearance of children (for appropriate time of day, if child or parent is ill or not) a. clean and well dressed b. dressed comfortably c. in diapers or underwear as visit was unexpected, however clearly warm and happy. d. Could use bathing, but no real signs of immenent neglect c. dirty, unkempt, clearly neglected (sagging, smelly diapers, dirty body and faces, use your parental judgement mark this if ONLY clear signs of severe neglect....etc.) comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 5. Appearance of house (which does not entail abuse except for extreme circumstances). Since this is of a subjective nature, your presence/eval as a third party witness is important. a. Very clean and neat. b. Clean and comfortable (it is OK for a family to have toys scattered about or laundry to fold on the living room floor or coach, a few dishes in the sink; judge by the overall appearance and your parental experience) c. In order....needs a little work done, but house NOT out of the ordinary for normal single or working parents. Perfectly acceptable for normal family. d. Very dirty, looks as if parent may need some help as they may be overwhelmed and could use a hand to get caught up. e. Very dangerous, signifigant animal feces accessable to children, rotten food on floors of house, beer or alchold cans everywhere...obvious need of cleaning....parent could be in need of professional cleaning and assistance. comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 6. Note questions by CPS agents: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 7. Note answers and comments by parents/children: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 8. How does parent interact with child/children during visit: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 9. How does CPS agent/officer interact with child/children during visit: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 10. Does CPS agent/officer lead questioning of child/children? comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 11. Do you know the nature of the complaint the CPS agent might be there for? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 12. Do the children appear to be abused? a. No signs of ANY bruising or Bodily harm in any way. b. does child just have any typical sraped knees, light bumps, or scratches typical of children with pets or that are very active in play (especially for boys or active girls). c. Uncanny and obvious, unexplanable bruising througout child's body that seem untypical of that of your own experience by a parent. comments:___________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 13. CPS agent's verbal explanation of resolution to visit: a. Unfounded, sorry to bother you. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ b. Wants to close case, but only after follow up-speaking with any references a parent could provide. How does parent react...willfully give out information or asks for parental rights? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ c. Wants parent to come into office to sign 'agreements' to 'rectify' issues and wants references, school information, physician information. However does not express need to take children into custody. Parent/Parents reaction: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ d. CPS agent with the assistance of law enforcement decides to take child/children into State custody against parents wishes. Parent and child's reactions. Explain fully how the removal effects both parent/child/CPS agent/officer: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ If child is to be removed answer your following observations, if not skip to question 14. 1. Does CPS agent explain how long child will remain in care? Does CPS agent threaten parent? Does CPS agent express plans on keeping child/children indefinetly? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 2. Does CPS agent ask about or attempt to locate a close relative before taking children. Does CPS agent allow parent to contact family member or close friend to take children as an alternative? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 3. What charges are made by CPS agent for taking the children into care? Imminent Danger? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 4. Are any arrest or criminal charges made at that time: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 5. Explain in detail how the removal emotionally effects the parent and child. (photograph, video tape, audio tape, and/or document this action). ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 14. How does the visit end? ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ 15. Your opinion as a parent and average citizen on the ethical, honesty of the CPS agent and the reason and outcome of the visit to this family. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Use separate paper for additional comments, if needed. I am a third party witness that was present on the said date. I was present during social services visit to the _______________ family home. I performed an independent evaluation of the actions of social services and the circumstances of the visit and home of the ____________family. The proceedings are my conclusions as a third party witness. ________________________, Independent Evaluator SUBSCRIBED AND SWORN TO before me this _______ day of ____________ , _____. ___________________________, NOTARY PUBLIC My commission expires: ________________________