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Dept.

of Family & Protective Services Form 2906


9-2006
Pg 1 of 2
CPA INTERNAL INVESTIGATION REPORT
(Please note: The use of this form is not mandatory ho!e"er# all information in$luded in
this re%ort must &e addressed in any a'en$y internal in"esti'ation re%ort()

Name of A'en$y O%eration*
Alle'ation+In$ident Information
Date agency learned of allegation/incident report agency
Date te allegation/incident occ!rred "ime occ!rred
#ame of Foster/$doptive %ome &if applica'le(
)dentification of individ!als involved in te allegation/incident &*se #/$ +ere appropriate(,
1. #ame $ge D-.
/!rrent address
"elepone #ame of Parent or 0/
Parent/0/ $ddress "elepone
)ntervie+ed 1es #o
2eason for intervie+
2. #ame $ge D-.
/!rrent address
"elepone #ame of Parent or 0/
Parent/0/ $ddress "elepone
)ntervie+ed 1es #o
2eason for intervie+
3. #ame $ge D-.
/!rrent address
"elepone #ame of Parent or 0/
Parent/0/ $ddress "elepone
)ntervie+ed 1es #o
2eason for intervie+
4. #ame $ge D-.
/!rrent address
"elepone #ame of Parent or 0/
Parent/0/ $ddress "elepone
)ntervie+ed 1es #o
2eason for intervie+
&$ttac anoter seet if necessary and/or any oter applica'le doc!mentation.(
Dept. of Family & Protective Services Form 2906
9-2006
Pg 2 of 2
CPA INTERNAL INVESTIGATION REPORT
Descri'e allegation/incident,
In"esti'ation A$ti"ities
2ecords revie+ed &)ncl!de te name of te record revie+ed(,
S!mmary of pertinent information o'tained from records revie+,
S!mmary of pertinent information o'tained from intervie+s,
Description and s!mmary of pertinent information of oter investigation activities &e.g.
o'servation of pysical plant(,
,inimum Standards and Guidelines for Child Pla$in' A'en$ies E"aluated:
In"esti'ation -indin's (in$ludin' the &asis for the findin's):
,inimum Standard .efi$ien$ies (if a%%li$a&le):
A'en$y %lan in$ludin' time limits for addressin' defi$ien$ies:
PLEASE NOTE: 5)/6#S)#7 26S6286S "%6 2)7%" "- /-#D*/" $#1
)#86S")7$")-# $#D/-2 "- 26-)#86S")7$"6 $#1 $5567$")-#/)#/)D6#"

#ame of te $gency Staff +o cond!cted te investigation

#ame and Signat!re of 5evel -ne Staff 0em'er
Date doc!mentation completed,
Date received 'y 5icensing,