CPS PARENTAL VISITATION DOCUMENTATION FORM

Date: _________________/_____/ 20_____

Place of Visitation: ______________________________________________

Address: _______________________________________

List of all who were present:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I arrived at _____:______  [   ] a.m. / [   ] p.m.   

My child(ren) was/were already there. Yes [ ] / no [ ]

My child(ren) arrived at ____:____  [   ] a.m. / [   ] p.m.

Others arrived at _____:______  [   ] a.m. / [   ] p.m.

Description of the conditions: 

My child(ren) arrived in or by __________________________________________;

Was Dressed Appropriately to the Weather Yes [ ] / No [ ] 

According to Family Cultural Norms Yes [ ] / No [ ]

Was Clean Yes [ ] /No [ ]

Any Marks or Bruises Found or Seen Yes [ ] / No [ ]

List of other obvious things:_________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Details of all interactions between children and me: 

read a book[ ]  changed a diaper[ ]   fed them[ ]   ate together[ ]

other interactions:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

(Everything should be clearly detailed.)

Description your child's behavior upon termination of the visit:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Concerned Notes of Things Said:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Other Details:
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I the undersigned attest that the above foregoing is true and accurate.

_______________________________________
Undersign signature

Date: ______/_______/ 2000

Other Witness Signatures: _________________________________ 

                          _________________________________

Dear Ms. ________________________________________,

If your version of events varies from mine in any way, please outline specifically any discrepancies you may find in writing within 10 days and summit that copy to me.

Sincerely,

__________________________________


CERTIFICATE OF SERVICE

THE UNDERSIGNED CERTIFIES THAT A FORGOING COPY OF THIS LETTER WAS DELIVERED BY MEANS OF THE FOLLOWING CHECKED BELOW:

Hand Delivered [ ]     By US Mail [ ]      Faxed By Phone [ ]


_________________________________

Signature of Delivering Party

Date:______________________/________/ 20_____