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The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Child, Family and Community Service Act (CFCS Act). Under certain circumstances, the collected information may be subject to disclosure as per the CFCS Act and/or the Freedom of Information and Protection of Privacy Act. Any questions about the collection, use or disclosure of this information should be directed to the Director, Child Welfare, (250) 953-4737, PO Box 9745, Stn Prov Govt, Victoria, B.C. V8W 9S5, email: MCF.StandardsPolicy@gov.bc.ca
 
 
 
Caregivers may be requested by their Resource Worker to complete a report each month for each child/youth that currently resides in the Caregiver's home. Once the report has been completed, the Caregiver provides the report to their Resource Worker. Please do not send this report to the Resource Worker via email. If you have any questions about completing this form, please contact your Resource Worker.
Report Date MM/DD/YYYY

Placement Date: MM/DD/YYYY

(555) 555-5555
(555) 555-5555
(555) 555-5555
(555) 555-5555
(555) 555-5555
(555) 555-5555

(e.g., mother, father, sibling, aunt, uncle)
MM/DD/YYYY

MM/DD/YYYY
Changes in Care Home, Illnesses and Accidents
Please include information about any changes in the home, including new residents, illnesses and accidents.

Has there been any involvement with the police/courts/lawyers since your last report?

Include incidents where the child/youth is absent and/or has stayed overnight outside the Caregiver’s home. Additionally, include where the child/youth has stayed with an alternate Caregiver (include the name of the alternate Caregiver).
(MM/DD/YYYY) and (AM/PM)
(MM/DD/YYYY) and (AM/PM)
(If appropriate, please include the name of the Alternate Caregiver).
Date
Time
Date
Time
Approved Relief
Please ensure that both a Criminal Record Check and Relief Care Provider Assessment Checklist is on file, as required. Please
provide the full name of who provided care, date, and location.
MM/DD/YYYY

Date: MM/DD/YYYY
Caregiver's Signature
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Caregiver provides their Resource Worker with the original monthly report.
MCFD Documentation Mangement
• The original signed Monthly Caregiver Report is filed in RE Section 7 - Child in Care Information.
• Child’s Worker/Guardianship Worker is provided with a copy of the report and it is filed in CS Section 5 – External Reports.
• If requested, provide a copy of the completed report to the Caregiver.
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