DCFS Youth and Foster Parent Study Contact Form

OMB NO: 0970-0408
EXPIRATION DATE: xxxxx

C6. DCFS Youth and Foster Parent Study Contact Form

Complete this form for each youth enrolled in the study after the foster parent declines or agrees to the release of their contact information.

YOUTH INFORMATION

Youth Name

Evaluation ID

Is the youth more comfortable reading in Spanish?
Yes	No

Foster Parent Contact Information

Did the foster parent agree to the release his/her contact information?
Yes	No (skip to caseworker section)

	Is this a new foster home within the last month?
Name	Yes	No

Phone:			Alternate Phone:
Address:
Apt/Room/Bldg:
City:			State:	Zip Code:

Caseworker Contact information

Name
	Phone:			Alternate Phone:

Work Address:
Room/Bldg:
City:			State:	Zip Code:

FOR OFFICE USE
Staff person who completed this document:
Date document completed:	/ /

Burden Statement: This collection of information is voluntary and will be used to evaluate the Permanency Innovations Initiative. Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Reports Clearance Officer (Attn: OMB/PRA 0970-0355), Office of Planning, Research and Evaluation, Administration for Children and Families, Department of Health and Human Services, 370 L’Enfant Promenade S.W., Washington DC 20447.