Form Cf 793 - Icpc District Transmittal Form

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PRIORITY
ICPC D
T
ISTRICT
RANSMITTAL
Must accompany all correspondence from worker/district if PRIORITY case/request
District/Region:____________________________________________________________________
Child’s Name (list alphabetically):______________________________________________________
Date Submitted to District/Region Specialist:__________________________________
County Name:________________________
ARS
FC
PS
CPI
Other
Counselor:_______________________________ Phone #:_____________
SC#:_____________
Supervisor:_______________________________ Phone #:_____________
SC#:_____________
Requesting a Home Study ..................
Priority Parent
Priority Relative
(send 3 packets)
Submitting a Home Study...................
Priority Parent
Priority Relative
(send 3 packets)
Approved Priority Home Study
Disapproved Priority Home Study
Requesting a Status Report ................
Priority Parent
Priority Relative
(send 3 packets)
Submitting a Status Report.................
Priority Parent
Priority Relative
(send 3 packets)
Requesting a Progress Report............
Priority Parent
Priority Relative
(send 3 packets)
Submitting a Progress Report.............
Priority Parent
Priority Relative
(send 3 packets)
Requesting Additional Information ......
Priority Parent
Priority Relative
(send 3 packets)
Submitting Additional Information .......
Priority Parent
Priority Relative
(send 3 packets)
Submitting Placement Confirmation/Change in Placement/Termination (100B) – send 1 set per child
Date Sent to Tallahassee:________________
ICPC Specialist Signature:____________________________________________________________
Proper Assembly of Material
Requesting Home Study – For each placement resource, complete 3 sets of the following items and securely fasten
one copy of each item (cover letter, social assessment, court order, PDS, Case Plan, Financial/Medical Plan,
additional Information) into 3 complete sets. Place the 100A’s on top of the entire request packet. Keep 1 copy of
the 100A for your file.
Submitting Home Studies/Progress Reports/Sending or Requesting Information to/from Other States – send 3
copies of Requests/Information with one copy of this transmittal on top of the packet. Staple, clip, or rubber band.
Submitting Placement Confirmation/Changes/Terminations – 1 set of 100B’s for each child (3 pages).
SORTING: Send three (3) identical sets of information (as specified above), with documents organized in the same
order and separated by either a sheet of colored paper or rubber bands. The completed and signed PRIORITY
District Transmittal Form with the completed 100A(s) should be placed on top of the entire three sets,
secured with a large rubber band.
CF 793, PDF 12/2005

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