1. (1) CASE RECORD MANAGEMENT

   1. (a) Written Policy Procedure and practice shall provide that a record is maintained for each juvenile and includes, at a minimum, the following information:

      1. 1. Name, age, sex, place of birth, and race or nationality
      2. 2. initial intake information form
      3. 3. authority to accept juvenile
      4. 4. referral source
      5. 5. case history/social history
      6. 6. medical consent forms
      7. 7. name, relationship, address, and phone number of parent(s)/guardian(s) and person(s) juvenile resides with at time of Admission
      8. 8. driver’s license number, social security number, and Medicaid number, when available
      9. 9. court orders and disposition
      10. 10. individual treatment plan or program
      11. 11. signed release of information forms
      12. 12. progress reports on program involvement
      13. 13. program rules and disciplinary policy, signed by juvenile
      14. 14. grievance and disciplinary record
      15. 15. referrals to other agencies and final discharge or transfer report
   2. (b) Written Policy, Procedure, and practice shall provide that new juveniles receive written orientation materials and/or translations in their own language if they do not understand English. When a literacy problem exists, a staff member assists the juvenile in understanding the material. Completion of orientation shall be documented by a signed statement signed and dated by the juvenile and participating staff.

2. (2) TRANSFER OF RECORDS

   1. (a) Written policy and procedure and practice provide that a juvenile’s updated case file is transferred within 72 hours of a change from one Program to another Program.

3. (3) CASE ASSIGNMENT

   1. (a) Written Policy, Procedure, and practice provide for assigning the case management of each juvenile to a staff member who meets with and counsels that juvenile.
   2. (b) Written Policy, Procedure, and practice require that all entries in the case record are signed and dated by the person making the entry.

4. (4) REPORTS

   1. (a) A report is prepared at the termination of program participation that reviews the juvenile’s performance and aftercare plans.

5. (5) RELEASE OF INFORMATION

   1. (a) Written Policy, Procedure, and practice provide that the Program uses a “release of information consent form” that complies with applicable federal and state regulations. An executed copy of the form is maintained in the juvenile’s case record.

6. (6) CONFIDENTIALITY

   1. (a) Written Policy, Procedure, and practice provide that records are safeguarded from unauthorized and improper disclosure. Manual records are marked “Confidential.” Written policy and procedure provide that when any part of the information system is computerized, security ensures confidentiality.

Author: Alabama Department of Youth Services, Office of Licensing and Standards

Statutory Authority: Code of Ala. 1975, §§44-1-27(a)(b), 44-1-24(4)(6), 38-13-4.

History: New Rule: Filed December 17, 2004; effective January 21, 2005. Amended: Filed November 6, 2018; effective December 21, 2018.