DCAC Clothes Closet Form

DCAC Clothes Closet Form
Caseworker Name*

First NameLast Name
Caseworker Email*
example@example.com
Case Name*
Case Number*
Foster Care?*

YesNo
Caregiver Name*

First NameLast Name
Caregiver's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Oldest Victim's Name (even if they are not receiving items)*

First NameLast Name
Oldest Victim's Date of Birth*

MonthDayYear
Date
Oldest Victim's Gender*

MaleFemaleOther
Is Oldest Victim Hispanic/Latino?*

YesNo
Oldest Victim's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Did Oldest Victim receive any items?*

YesNo
How many children received items (including the Oldest Victim)?*
Case Type (check all that apply)*

Minor with PSBNSUPPHABSXABSXTRWitness to HomicideWitness to ViolenceSibling of Child DeathSibling of Physical AbuseSibling of Sexual AbuseSibling Witness to HomicideSibling Witness to ViolenceOther
Alleged Perpetrator's Name*

First NameLast Name
Alleged Perpetrator's Relationship to Victim*
Alleged Perpetrator Gender*

MaleFemaleOther
Alleged Perpetrator DOB*

MonthDayYear
Date
Items Taken (check all that apply)

Air mattressBaby items (bottles, formula, pacifiers, etc.)Bedding/quilt/blanketBirthday bag(s)Car seatClean Start Bag (bag w/ cleaning supplies)Clothing and/or shoesDiapers/wipesJust For You Bags/Boxes (w/ toiletries)Pack 'n' PlaySchool suppliesToiletriesToys
Second Child's Name (even if they are not receiving items)*

First NameLast Name
Second Child's Date of Birth*

MonthDayYear
Date
Second Child's Gender*

MaleFemaleOther
Is Second Child Hispanic/Latino?*

YesNo
Second Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Second Child's Relationship to Oldest Victim*
Is this Second Child also a victim of the same AP*

YesNo
Third Child's Name (even if they are not receiving items)*

First NameLast Name
Third Child's Date of Birth*

MonthDayYear
Date
Third Child's Gender*

MaleFemaleOther
Is Third Child Hispanic/Latino?*

YesNo
Third Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Third Child's Relationship to Oldest Victim*
Is this Third Child also a victim of the same AP*

YesNo
Fourth Child's Name (even if they are not receiving items)*

First NameLast Name
Fourth Child's Date of Birth*

MonthDayYear
Date
Fourth Child's Gender*

MaleFemaleOther
Is Fourth Child Hispanic/Latino?*

YesNo
Fourth Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Fourth Child's Relationship to Oldest Victim*
Is this Fourth Child also a victim of the same AP*

YesNo
Fifth Child's Name (even if they are not receiving items)*

First NameLast Name
Fifth Child's Date of Birth*

MonthDayYear
Date
Fifth Child's Gender*

MaleFemaleOther
Is Fifth Child Hispanic/Latino?*

YesNo
Fifth Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Fifth Child's Relationship to Oldest Victim*
Is this Fifth Child also a victim of the same AP*

YesNo
Sixth Child's Name (even if they are not receiving items)*

First NameLast Name
Sixth Child's Date of Birth*

MonthDayYear
Date
Sixth Child's Gender*

MaleFemaleOther
Is Sixth Child Hispanic/Latino?*

YesNo
Sixth Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Sixth Child's Relationship to Oldest Victim*
Is this Sixth Child also a victim of the same AP*

YesNo
Seventh Child's Name (even if they are not receiving items)*

First NameLast Name
Seventh Child's Date of Birth*

MonthDayYear
Date
Seventh Child's Gender*

MaleFemaleOther
Is Seventh Child Hispanic/Latino?*

YesNo
Seventh Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Seventh Child's Relationship to Oldest Victim*
Is this Seventh Child also a victim of the same AP*

YesNo
Eighth Child's Name (even if they are not receiving items)*

First NameLast Name
Eighth Child's Date of Birth*

MonthDayYear
Date
Eighth Child's Gender*

MaleFemaleOther
Is Eighth Child Hispanic/Latino?*

YesNo
Eighth Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Eighth Child's Relationship to Oldest Victim*
Is this Eighth Child also a victim of the same AP*

YesNo
Ninth Child's Name (even if they are not receiving items)*

First NameLast Name
Ninth Child's Date of Birth*

MonthDayYear
Date
Ninth Child's Gender*

MaleFemaleOther
Is Ninth Child Hispanic/Latino?*

YesNo
Ninth Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Ninth Child's Relationship to Oldest Victim*
Is this Ninth Child also a victim of the same AP*

YesNo
Tenth Child's Name (even if they are not receiving items)*

First NameLast Name
Tenth Child's Date of Birth*

MonthDayYear
Date
Tenth Child's Gender*

MaleFemaleOther
Is Tenth Child Hispanic/Latino?*

YesNo
Tenth Child's Race?*

Black/African AmericanWhiteAmerican Indian/Alaska NativeAsianNative Hawaiian/or Other Pacific IslanderMulti-racialOther
Tenth Child's Relationship to Oldest Victim*
Is this Tenth Child also a victim of the same AP*

YesNo
Should be Empty: