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:COU 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.IL Transitional Support (18-22) Sample 1-5 Child 1 Child 2 Child 3 Child 4 Child 5Child Last Name, First InitialChild Record NumberChild Date of BirthCalculated: 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!Date of 18th Birthday 12/31/1917 12/31/1917 12/31/1917 12/31/1917 12/31/1917Last Date Before 23rd Birthday 12/30/1922 12/30/1922 12/30/1922 12/30/1922 12/30/1922IL Transitional Support (18-22) Sample 6-10 Child 6 Child 7 Child 8 Child 9 Child 10Child Last Name, First Initial