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Library: Policy

340:75-6-40.2. Placement provider information


Revised 7-1-13

     Form 04KI004E, Placement Provider Information, is a component of the case plan and is provided to the child's out-of-home placement provider.  The form includes the most recent information available about the child required by Section 1-7-104 of Title 10A of the Oklahoma Statutes, but is not limited to, available information regarding:

  • (1) demographic information;

  • (2) the child's strengths, needs, and general behavior;

  • (3) circumstances necessitating the child's placement;

  • (4) type of custody and child's previous placement;

  • (5) pertinent family information including, but not limited to:

    • (A) names of family members who are and who are not, by court order, allowed to visit the child; and

    • (B) the child's relationship to family that might affect placement;

  • (6) known and important life experiences and relationships that may significantly affect the child's feelings, behavior, attitudes, or adjustment;

  • (7) whether third-party insurance coverage may be available to the child;

  • (8) education history including present grade placement, last school attended, and special strengths and weaknesses.  OKDHS assists the foster parent with the child's school admittance and enrollment and obtaining the child's school records;

  • (9) known or available medical history including, but not limited to:

    • (A) allergies;

    • (B) childhood diseases;

    • (C) immunizations;

    • (D) physical handicaps;

    • (E) psycho-social information; and

    • (F) the name of the child's last doctor, if known; and

  • (10) sufficient medical information regarding the child to enable the placement provider to care for the child safely and appropriately, including, but not limited to:

    • (A) any medical or psychological conditions;

    • (B) diseases, illnesses, accidents, allergies, or congenital defects;

    • (C) the child's SoonerCare card or information on other third-party insurer, if any; and

    • (D) immunization history.


Revised 7-1-13

1.Placement provider information.When the child in Oklahoma Department of Human Services (OKDHS) custody is placed in out-of-home care or moved from one placement to another, the child welfare (CW) specialist provides the placement provider all known information concerning the child at the time of the placement.

(1) When information is not available, the CW specialist takes immediate steps to acquire and furnish the information to the placement provider no later than 14 calendar days from the placement.

(2) Form 04KI004E, Placement Provider Information, is printed from the reports icon in KIDS, and builds from information in the KIDS system.The information populated by the KIDS system into Form 04KI004E will change as information is added or modified within KIDS.

(3) Form 04KI004E is reprinted every six months for the placement provider.

(4) The CW specialist obtains the placement provider's signature on Form 04KI004E and provides a copy to the placement provider.

(5) Form 04KI004E is completed and provided to the placement provider each time the child changes placement except when the child is placed in his or her own home or in a shelter.

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