100A Elements
| Item |
Element
|
Questions/Issues
|
| 1 |
Receiving State Compact Administrator
Name
Address
|
|
| 2 |
Sending State Compact Administrator Name
Name
Address
|
|
| 3 |
ICPC Client
Name
Sex
DateOfBirth
Ethnicity
|
|
| 4 |
Father
Name
|
|
| 5 |
Mother
Name
|
|
| 6 |
ChildPlanner **
Name
|
**Who are we talking about - worker,
supervisor, etc.?
|
| 7 |
Planning Agency
OrganizationName
TelephoneNumber
Address
|
|
| 8 |
PersonFinanciallyRepsonsibleForChild
Name
|
|
| 9 |
AgencyFinanciallyResponsibleForChild
OrganizationName
TelephoneNumber
Address
|
|
| 10 |
PersonChildToBePlacedWith
Name
|
|
| 11 |
AgencyChildToBePlacedWith
OrganizationName
TelephoneNumber
Address
|
|
| 12 |
PlacementCareType ** |
**Comply with AFCARS/Foster Care data
element 41?
|
| 13 |
SubsidyIVEAssistance
Indicator
|
|
| 14 |
StateResponsibleForSubsidyIVE |
|
| 15 |
ChildIVEEligible
Indicator
|
|
| 16 |
LegalStatus |
**Which values will we use? Also, will we
break out different attributes?
|
| 17 |
InitialReportRequested |
|
| 18 |
SupervisoryServicesRequested |
|
| 19 |
SupervisoryReportsTimeFrame
Value
Other Description
|
|
| 20 |
AgencySupervisingICPCPlacement
OrganizationName
Address
|
|
| 21 |
SocialHistoryAttachment
Indicator
|
|
| 22 |
HomeStudyAttached
Indicator
|
|
| 23 |
CourtOrderAttached
Indicator
|
|
| 24 |
OtherEnclosuresAttached
Indicator
Other Description
|
|
| 25 |
NameOfSendingAgencyPerson** |
**What will we use for signature?
|
| 26 |
DateOfSignature |
|
