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:

_______________________________________________________________________
_______

_______________________________________________________________________
_______

_______________________________________________________________________
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Other Details:
_______________________________________________________________________
_______

_______________________________________________________________________
_______

_______________________________________________________________________
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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_____