(a) All social services districts must establish and maintain a single uniform case record for each family for whom a case record is required pursuant to section 428.1 of this Part.

1. (1) Each uniform case record must include, but need not be limited to the following items in the form and manner prescribed by OCFS:

   1. (i) a common application form;
   2. (ii) family assessments and service plans at regularly scheduled intervals in accordance with subdivision (f) of this section;
   3. (iii) plan amendments, as required by section 428.7 of this Part completed for each status change;
   4. (iv) all forms for the child care review service pursuant to sections 406.4 and 465.1 of this Title, for as long as that system remains the official system of record of OCFS;
   5. (v) face sheet;
   6. (vi) progress notes in the form and manner prescribed by OCFS;
   7. (vii) all official documents and records of any judicial or administrative proceedings relating to the district's contact with a child and/or a family, including but not limited to records of petitions, permanency hearing reports and notices, court orders, probation reports, voluntary instruments or agreements, fair hearings, administrative reviews, and the results of any examinations or evaluations ordered by a court;
   8. (viii) all correspondence between the family, the district and/or purchase of service agencies;
   9. (ix) information received from private or public purchase of service agencies, concerning casework contacts with a child and/or his or her family receiving family and children services; and
   10. (x) all documentation relating to the establishment of categorical eligibility for any funding source for which the child or family may be eligible.

2. (2) For foster care placement cases, additional information and documents must also include:

   1. (i) data and official documents relating to the identification and/or history of a child and/ or his/her family, including but not limited to copies of birth certificates, documentation of religion, documentation of the child's immigration status, and any consent forms and/or religious preference forms signed by the parent or guardian;
   2. (ii) all reports of medical or clinical examinations or consultations, including medical examinations and laboratory tests, psychiatric or psychological examinations or consultations (either court-ordered or voluntary), dental examinations; and medical consent forms signed by the parent or guardian, by the commissioner of the social services district, or by the child if the child has the capacity to consent, as applicable, regarding medical treatment for any child in foster care placement, including documentation that the child has been assessed for risk factors related to HIV infection in accordance with section 441.22(b) of this Title, and, if one or more risk factors have been identified, a description of the procedures that were followed to arrange for appropriate HIV-related testing including obtaining the necessary written informed consent for such testing;
   3. (iii) educational and/or vocational training reports or evaluations indicating the educational goals and needs of each foster child, including school reports and Committee on Special Education evaluations and/or recommendations;
   4. (iv) the child's transition plan prepared in accordance with the standards set forth in section 430.12(j) of this Title; and
   5. (v) the foster child's consumer report provided in accordance with section 430.12(k) of this Title.

3. (3) For foster care placement cases in which the child is placed in a qualified residential treatment program as defined in section 441.2 of this Title, the uniform case record must also include:

   1. (i) details regarding the family and permanency team, including but not limited to:

      1. (a) its composition;
      2. (b) the reasonable and good faith effort to identify and include all the individuals described in section 409-h of the Social Services Law and section 439.3 of this Title to participate in the family and permanency team;
      3. (c) all contact information for members of the family and permanency team, as well as contact information for other family members and fictive kin who are not part of the family and permanency team;
      4. (d) evidence that meetings of the family and permanency team, including meetings relating to the assessment required under section 409-h of the Social Services Law, are held at a time and place convenient for the family;
      5. (e) if reunification is the goal, evidence demonstrating that the parent from whom the child was removed provided input from the members of the family and permanency team;
      6. (f) evidence that the assessment required under section 409-h of the Social Services Law is determined in conjunction with the family and permanency team;
      7. (g) the placement preferences of the family and permanency team relative to the assessment that recognizes children should be placed with their siblings unless there is a finding by the court that such placement is contrary to their best interest; and
      8. (h) if the placement preferences of the family and permanency team and child are not the placement setting recommended by the qualified individual conducting the assessment under section 409-h of the Social Services Law, the reasons why the preferences of the team and of the child were not recommended;

   2. (ii) details regarding the assessment conducted by the qualified individual, as such term is defined in section 441.2 of this Title, including, but not limited to:

      1. (a) the written assessment completed by a qualified individual; and
      2. (b) the determination of whether the child’s needs can be met in a foster home, and if it was determined by the qualified individual that the needs of the child cannot be met by the family of the child or in a foster family home, in accordance with section 409-h of the Social Services Law, the specific reasons why; and
   3. (iii) documentation of the court’s findings at the court review of the placement in a qualified residential treatment program in accordance with sections 393 of the Social Services Law, or section 353.7, 756-b, 1055-c, 1091-a, or 1097 of the Family Court Act, as may be applicable;
   4. (iv) if the child meets the definition of long stayer as provided for in section 439.5 of this Title and a long stayer review is conducted in accordance with that section, the determination of the commissioner of OCFS, or the commissioner’s designee, regarding the appropriateness of the child’s continued placement in a qualified residential treatment program.
4. (4) If a youth is parenting a child, as part of a parenting youth and child of parenting youth unit as defined in section 427.2 of this Title, the uniform case record shall be updated to include information on casework contacts with both the parenting youth and child of the parenting youth as required under section 441.21 of this Title.

(b)

(d) Each family assessment and service plan, must document the involvement of the parent(s) or guardian and, where appropriate, child(ren) 10 years or older, including children in foster care and their siblings or half-siblings and children placed by a court in the direct custody of a relative or other suitable person pursuant to article 10 of the Family Court Act, in the development of the plan, or must document efforts to involve them in the development of the plan. Such efforts must include, but are not limited to:

1. (1) encouraging parent(s) or guardian and the children to participate in the development and review of the plan, and attempting to obtain the parent(s)' or guardian's signatures documenting their review of the plan; and
2. (2) where parent(s) or guardian and/or children are not able to participate in the development of the plan and arrangements cannot be made to allow participation, conveying the contents of the service plan and any recommendations to them, and attempting to obtain the parent(s)' or guardian's comments and signatures documenting their review of the plan.

(e) For foster care cases and for children placed by a court in the direct custody of a relative or other suitable person pursuant to article 10 of the Family Court Act, the service plan review requirements of section 428.9 of this Part also apply.

1. (1) Social services districts must initiate a uniform case record for a family on the case initiation date as defined in section 428.2(a) of this Part.

2. (2) On the case initiation date, the following must be completed and become part of the uniform case record:

   1. (i) a common application form; and
   2. (ii) face sheet or equivalent in accordance with section 428.4 of this Part.
3. (3) Documentation of casework activity and contacts in progress notes must begin on the case initiation date or, for cases where a report has been accepted by the Statewide central register, casework activity must be recorded in progress notes from the date of receipt of the report of suspected abuse or maltreatment.
4. (4) Except for open indicated child abuse and maltreatment cases, an initial family assessment and service plan must be completed by the social services district or by a provider agency providing services pursuant to a purchase of service agreement, and must be approved by the case manager within 30 days from the case initiation date. For open indicated child abuse and maltreatment cases, an initial family assessment and service plan must be completed by the social services district or the provider agency providing services pursuant to a purchase of service agreement, and approved by the case manager within seven days of the date that a report to the Statewide central register is determined to be indicated.
5. (5) A comprehensive family assessment and service plan must be completed by the social services district or by a provider agency providing services pursuant to a purchase of service agreement and must be approved by the case manager within 90 days from the case initiation date.
6. (6) The first family reassessment and service plan must be completed by the social services district or by the provider agency providing services pursuant to a purchase of service agreement, and must be approved by the case manager no later than 210 days from the case initiation date. All subsequent family reassessment and service plan reviews must be completed by the social services district or by the provider agency providing services pursuant to a purchase of service agreement, and must be approved by the case manager six months from the due date of the previous reassessment and every six months thereafter.
7. (7) A plan amendment must be completed by the social services district or by the provider agency providing services pursuant to a purchase of service agreement, and must be approved by the case manager for the case, in accordance with the requirements of section 428.7 of this Part, whenever a significant change occurs in the status of the case.

(f) Case process flow.