Independent Living Program - Florida's Center for Child Welfare

Complete the white cells below and in the sample tables. For more than thirty children in a sample, start a new file.Provider Name: Provider City: Contract Number: Service Description: Independent LivingCOU Team Member: Site Visit Date: Assigned COU: Below enter the actual date of the record review, or enter the last date of the review period.This date will be used to calculate children's ages and the length of time since removal.Pre IL (Age 13-14) Sample 1-5 Child 1 Child 2 Child 3 Child 4 Child 5Child Last Name, First InitialChild Record NumberChild Date of BirthChild Most Recent Date of Entry into Licensed CareCalculated: Child's Age in Years #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!Calculated: Child's Age in Months #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!Child's Age at Time of Review #VALUE! #VALUE! #VALUE! #VALUE! #VALUE!Calculated: Child's Age in Years - Time of Removal 0 0 0 0 0Calculated: Child's Age in Months - Time of Removal 0 0 0 0 0Child's Age at Time of Removal 0 yrs 0 mths 0 yrs 0 mths 0 yrs 0 mths 0 yrs 0 mths 0 yrs 0 mthsCalculated Date: 30 Days Prior to 13th Birthday 12/1/1912 12/1/1912 12/1/1912 12/1/1912 12/1/1912Calculated Date: 30 Days After Removal 1/30/1900 1/30/1900 1/30/1900 1/30/1900 1/30/1900Due Date of IL Referral 12/1/1912 12/1/1912 12/1/1912 12/1/1912 12/1/1912Calculated Date: 30 Days After 13th Birthday 1/30/1913 1/30/1913 1/30/1913 1/30/1913 1/30/1913Calculated Date: 60 Days After Removal 2/29/1900 2/29/1900 2/29/1900 2/29/1900 2/29/1900Due Date of Assessment 1/30/1913 1/30/1913 1/30/1913 1/30/1913 1/30/1913