DCAC Clothes Closet Form
Caseworker Name
*
First Name
Last Name
Caseworker Email
*
example@example.com
Case Name
*
Case Number
*
Foster Care?
*
Yes
No
Caregiver Name
*
First Name
Last Name
Caregiver's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Oldest Victim's Name (even if they are not receiving items)
*
First Name
Last Name
Oldest Victim's Date of Birth
*
-
Month
-
Day
Year
Date
Oldest Victim's Gender
*
Male
Female
Other
Is Oldest Victim Hispanic/Latino?
*
Yes
No
Oldest Victim's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Did Oldest Victim receive any items?
*
Yes
No
How many children received items (including the Oldest Victim)?
*
Case Type (check all that apply)
*
Minor with PSB
NSUP
PHAB
SXAB
SXTR
Witness to Homicide
Witness to Violence
Sibling of Child Death
Sibling of Physical Abuse
Sibling of Sexual Abuse
Sibling Witness to Homicide
Sibling Witness to Violence
Other
Alleged Perpetrator's Name
*
First Name
Last Name
Alleged Perpetrator's Relationship to Victim
*
Alleged Perpetrator Gender
*
Male
Female
Other
Alleged Perpetrator DOB
*
-
Month
-
Day
Year
Date
Items Taken (check all that apply)
Air mattress
Baby items (bottles, formula, pacifiers, etc.)
Bedding/quilt/blanket
Birthday bag(s)
Car seat
Clean Start Bag (bag w/ cleaning supplies)
Clothing and/or shoes
Diapers/wipes
Just For You Bags/Boxes (w/ toiletries)
Pack 'n' Play
School supplies
Toiletries
Toys
Second Child's Name (even if they are not receiving items)
*
First Name
Last Name
Second Child's Date of Birth
*
-
Month
-
Day
Year
Date
Second Child's Gender
*
Male
Female
Other
Is Second Child Hispanic/Latino?
*
Yes
No
Second Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Second Child's Relationship to Oldest Victim
*
Is this Second Child also a victim of the same AP
*
Yes
No
Third Child's Name (even if they are not receiving items)
*
First Name
Last Name
Third Child's Date of Birth
*
-
Month
-
Day
Year
Date
Third Child's Gender
*
Male
Female
Other
Is Third Child Hispanic/Latino?
*
Yes
No
Third Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Third Child's Relationship to Oldest Victim
*
Is this Third Child also a victim of the same AP
*
Yes
No
Fourth Child's Name (even if they are not receiving items)
*
First Name
Last Name
Fourth Child's Date of Birth
*
-
Month
-
Day
Year
Date
Fourth Child's Gender
*
Male
Female
Other
Is Fourth Child Hispanic/Latino?
*
Yes
No
Fourth Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Fourth Child's Relationship to Oldest Victim
*
Is this Fourth Child also a victim of the same AP
*
Yes
No
Fifth Child's Name (even if they are not receiving items)
*
First Name
Last Name
Fifth Child's Date of Birth
*
-
Month
-
Day
Year
Date
Fifth Child's Gender
*
Male
Female
Other
Is Fifth Child Hispanic/Latino?
*
Yes
No
Fifth Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Fifth Child's Relationship to Oldest Victim
*
Is this Fifth Child also a victim of the same AP
*
Yes
No
Sixth Child's Name (even if they are not receiving items)
*
First Name
Last Name
Sixth Child's Date of Birth
*
-
Month
-
Day
Year
Date
Sixth Child's Gender
*
Male
Female
Other
Is Sixth Child Hispanic/Latino?
*
Yes
No
Sixth Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Sixth Child's Relationship to Oldest Victim
*
Is this Sixth Child also a victim of the same AP
*
Yes
No
Seventh Child's Name (even if they are not receiving items)
*
First Name
Last Name
Seventh Child's Date of Birth
*
-
Month
-
Day
Year
Date
Seventh Child's Gender
*
Male
Female
Other
Is Seventh Child Hispanic/Latino?
*
Yes
No
Seventh Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Seventh Child's Relationship to Oldest Victim
*
Is this Seventh Child also a victim of the same AP
*
Yes
No
Eighth Child's Name (even if they are not receiving items)
*
First Name
Last Name
Eighth Child's Date of Birth
*
-
Month
-
Day
Year
Date
Eighth Child's Gender
*
Male
Female
Other
Is Eighth Child Hispanic/Latino?
*
Yes
No
Eighth Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Eighth Child's Relationship to Oldest Victim
*
Is this Eighth Child also a victim of the same AP
*
Yes
No
Ninth Child's Name (even if they are not receiving items)
*
First Name
Last Name
Ninth Child's Date of Birth
*
-
Month
-
Day
Year
Date
Ninth Child's Gender
*
Male
Female
Other
Is Ninth Child Hispanic/Latino?
*
Yes
No
Ninth Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Ninth Child's Relationship to Oldest Victim
*
Is this Ninth Child also a victim of the same AP
*
Yes
No
Tenth Child's Name (even if they are not receiving items)
*
First Name
Last Name
Tenth Child's Date of Birth
*
-
Month
-
Day
Year
Date
Tenth Child's Gender
*
Male
Female
Other
Is Tenth Child Hispanic/Latino?
*
Yes
No
Tenth Child's Race?
*
Black/African American
White
American Indian/Alaska Native
Asian
Native Hawaiian/or Other Pacific Islander
Multi-racial
Other
Tenth Child's Relationship to Oldest Victim
*
Is this Tenth Child also a victim of the same AP
*
Yes
No
Submit
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