Form for Report of Child Abuse and Protective Services

The report of child abuse and protective services pursuant to Pa.R.Civ.P. 1915.3-3 shall be substantially in the following form: (Caption) CRIMINAL RECORD / ABUSE HISTORY VERIFICATION REPORT CHILD ABUSE AND PROTECTIVE SERVICES REQUESTED BY COURT (Court may use the first page of the parties’ criminal record/abuse history verification or may complete a new form.) 1. Participants. Please list ALL members in your/the participant’s household and attach sheets if necessary: Name Date of Birth Address Relationship to Child(ren) Party requests their residence remain confidential as they are protected by the Protection from Abuse Act, 23 Pa.C.S. § 6112, or the Domestic and Sexual Violence Victim Address Confidentiality Act, 23 Pa.C.S. § § 6701—6713, or the Child Custody Act, 23 Pa.C.S. § 5336(b), or they are in the process of seeking protection under the same. Please list ALL members in the opposing party’s household and attach sheets if necessary: SUBJECT CHILD(REN)—Attach additional sheets if necessary: Name Date of Birth ***End of Page 1*** TO BE COMPLETED BY THE COUNTY AGENCY: CHECK ALL THAT APPLY: No information on this family within county agency records. Child Protective Services (Complete CPS section below). General Protective Services (Complete GPS section below). 2. Child Protective Services (CPS) Cases: Was any child(ren), listed above, subject of an indicated report of child abuse? Circle your response and supplement, if indicated. Yes No If yes, indicate date(s) of incident(s) and name(s): Was any child(ren), listed above, subject of a founded report of child abuse? Yes No If yes, indicate date(s) of incident(s) and name(s): Has a party or member of the party’s household been identified as the perpetrator in an indicated report of child abuse? Yes No If yes, indicate date(s) of incident(s) and name(s): Has a party or member of the party’s household been identified as the perpetrator in a founded report of child abuse? Yes No If yes, indicate date(s) of incident(s) and name(s): If any of the questions above are answered ‘‘Yes,’’ provide the following information: Name of county agency: County agency caseworker(s): (please list current or most recently assigned, if known) County agency supervisor(s): (please list current or most recently assigned, if known) For each instance, please provide: (attach additional sheets if necessary to provide the information below for additional participants) A. Determination date of indicated or founded CPS referral(s): B. Was a service provided? No If answered ‘‘No,’’ skip questions C, D, E, and F. Yes If answered ‘‘Yes,’’ please list the type of service(s) and name of service provider(s): C. Date services ended, if applicable: D. Who received the services? E. Services were: Voluntary Court-ordered If court-ordered, please provide the docket number: F. Generally describe the services provided: G. If the county agency made referrals to outside providers, list the type of service and the name of the service provider: 3. General Protective Services (GPS) Cases : Has a party or a member of a party’s household been provided services? Circle your response and supplement, if indicated. Yes No If answered ‘‘Yes,’’ provide the following information: The concerns identified on the GPS referral(s) were: Valid Invalid Determination date: Was a service provided? No If answered ‘‘No,’’ skip questions C, D, E and F. Date GPS services ended, if applicable: Who received GPS services? E. GPS Services were: Voluntary Court-ordered. If court-ordered, please provide the docket number: 4. Dependency Cases : Is the child currently adjudicated dependent? Circle your response and supplement, if indicated. Name of county where the case is filed: Docket number of case: (please list current or most recently assigned, if known) NOTICE The completed form shall be confidential and not publicly accessible. Further dissemination by the recipients of the form is in violation of 23 Pa.C.S. Ch. 63 (Child Protective Services Law). Comment: Rule 1915.25(c) suspends 23 Pa.C.S. § 6339, insofar as it is inconsistent with this rule. Source The provisions of this Rule 1915.3-4 added April 25, 2025, effective July 1, 2025, 55 Pa.B. 3342. 1. Party requests their residence remain confidential as they are protected by the Protection from Abuse Act, 23 Pa.C.S. ***End of Page 1*** TO BE COMPLETED BY THE COUNTY AGENCY: TO BE COMPLETED BY THE COUNTY AGENCY: County agency supervisor(s): For each instance, please provide: A. No If answered ‘‘No,’’ skip questions C, D, E, and F. E. The completed form shall be confidential and not publicly accessible.