Our vision is that every child involved in the child welfare or juvenile justice systems becomes resilient, safe, healthy, and economically secure.

Care Giver Questionnaire - DHHS

This survey is for anyone who is providing the 24/7 care of the child/youth, regardless of the placement type.

What is reported in this questionnaire may be included in the local board's report to the legal parties to the case.

Your First Name: Required

Your Last Name: Required

Your Email Address:

If responding for more than one child, use the oldest child's first name and last initial.

Child's First Name: Required

Child's Last Name: (1st Initial Only) Required

City: Required

State: Required

Board #: If Known

Meeting Date: If Known

System Contact

Have you received enough background information on the child(ren) to meet his/her needs? (example – Medical/educational/ behavioral/ and/or any other special needs)?

Explain

Do you receive regular information updates from the Case Manager?

Explain

Do you feel more contact or information is needed?

Explain

Has the guardian ad litem visited with either you or the children in the home and was this interaction helpful?

Explain

You have a right to be notified and attend court hearings. Do you attend these court hearings?
Yes No

What has been your experience?

Services

Is the child(ren) receiving appropriate services?

Explain

Are there any unmet needs or concerns?

Explain

Describe any positive/negative behaviors of the child(ren)?

Explain

Are the child(ren)'s age appropriate developmental needs being met?

Explain

Education/Wellbeing

Is the child(ren) enrolled in school?
Yes No

Describe what extracurricular activities the child(ren)enjoy and are involved in.

Explain

Is there anything keeping the child(ren) from being involved in these activities?

Explain

Are educational and age appropriate developmental needs being met?

Explain

Please list any child(ren) in your care that have an Individualized Education Plan (IEP) and include if appropriate services are in place and active.

Explain

Please list any child(ren) in your care that have developmental disabilities and if appropriate services are provided/needed.

Explain

Describe the age appropriate life skills you are teaching the children/youth and do you need assistance?

Explain

Is the child(ren) 16 years or older?
Yes No

Do they have a learner's permit, driver's license, a part time job etc.

Explain

If the child/ren is 18 years or older, do do they have access to important documents such as a Social Security Card, birth certificate, medical and educational records, pictures, etc. in preparation for turning 19?

Explain

Additional Information

is there anything else you would like us to know?

Explain

Although not required, if you would like to submit any additional related documents you may do so below:

Total file size for all files cannot exceed 17MB.

File Upload (pdf, xls, xlsx, doc, docx, jpg, png, gif, tiff, txt)

By the return of this document online, you attest that the information is true and accurate.

Please call the System Oversight Specialist on this case at the phone number listed in the letter you received. Otherwise call our main office at 402-471-4420 for assistance.

Security Authentication Required

For security purposes, you must complete the recaptcha before submitting the form.

"The soul is healed by being with children." Fyodor Dostoevsky

"There is no trust more sacred than the one the world holds with children." Kofi A. Annan