Form Rfa 9099 - Complaint Investigation Report Page 2
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3State of California – Health and Human Services Agency
California Department of Social Services
Substantiated
Inconclusive
Unfounded
Needs Further Investigation
Estimated days for completion:
(Public)
(Public)
(Confidential)
USE RFA 9099(C) TO DOCUMENT SUBSTANTIATED ALLEGATION(S).
I acknowledge receipt of this report and understand my appeal rights as explained on the following page of
this form.*
RF Printed Name:
Telephone Number:
RF Signature:
Date:
RR Worker Printed Name:
Telephone Number:
RF Worker Signature:
Date:
RF Worker Supervisor Printed Name:
Telephone Number:
*
RFA Worker: C heck this box if a Resource Family parent was not available to sign the report.
Immediately mail the report by certified mail to the Resource Family address
of record.
RFA 9099 (10/17) (Mandatory)
Page 2 of ____
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