New Transportation Request Replaced as of 9/7/17 @1pm
  1. Job Type(*)





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  2. --------------------VERIFICATION SECTION--------------------

  3. Is the birth parent required to confirm? (*)
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  4. Note**Confirmation number is 412 342 0618. Birth parent must confirm by 5PM the day before the visit.

  5. Are there any barriers to the Kinship Caregiver hosting visits in their home?(*)
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  6. Are there any barriers to the Birth Parent hosting visits in their home?(*)
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  7. Can Kinship Caregiver provide transportation? (*)
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  8. If no state the barrier(s)
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  9. Can Bus and / or MAT be used?(*)
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  10. Are these visits court ordered?(*)
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  11. Fax/email order to: 412 342 0802 or send a email to transportationdepartment@asecondchance-kinship.com

  12. Reason for Placement(*)
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  13. If Other is selected, please provide the information.
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  14. Any Special Instructions?(*)
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  15. If Yes, list the Instructions
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  16. --------------------TRANSPORTATION REQUEST INFORMATION SECTION--------------------

  17. Note**Please note, there are two types of transports that we will coordinate: Open-Ended and Specific. ASCI will schedule all Open Ended transports in collaboration with the members of the triad, others involved in the transport and our time parameters. Additionally, because we believe that a collaborative approach is in the best interest of the child, we will involve all members of the triad in the transportation process to reschedule specific transports at a time that is convenient to all involved and meets our time parameters as well. We will advise you of any schedule changes that are made.

  18. Type of Schedule(*)
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  19. If the visit is Open Ended, answer the next four questions then skip to Demographic Section.

  20. Number of Hours per Visit
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  21. Frequency of Visit
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  22. Begin Date of Visit
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  23. End Date of Visit
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  24. Note**If the visit is a Specific Schedule, answer the next seven questions then skip to Demographic Section

  25. Date of Request
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  26. Date Transport to Begin
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  27. Date Transport to End
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  28. Reoccuring Trips
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  29. Day of the Week
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  30. Time of Visit
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  31. Return Time from Visit
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  32. --------------------DEMOGRAPHIC SECTION--------------------

  33. Name and Relationship of Person to Visit(*)
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  34. Phone Number of Person to Visit
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  35. Pick Up Address (include City, State, Zip)(*)
    Please check Pick Up Address field: Example: 8350 Frankstown Ave Pittsburgh,Pa,15221
  36. Pick-up Contact Name and Phone Number(*)
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  37. Should the Child be Accompanied?(*)
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  38. If Yes, Who Should Accompany the Child/Children
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  39. Destination Address(*)
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  40. City(*)
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  41. State(*)
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  42. Zip Code(*)
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  43. Destination Contact Name and Phone Number(*)
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  44. Return Address (include City, State,Zip)(*)
    Please check Return Address field: Example: 8350 Frankstown Ave Pittsburgh,Pa,15221
  45. Return Contact Name and Phone Number(*)
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  46. Child or Children Names(*)
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  47. Ex: FirstName LastName, (Please include the space in between and comma at the end of each child)
  48. Child or Children Date of Birth(*)
    Please check Child or Children Date of Birth field: Example: 10-04-2014
  49. List respectively (MM-DD-YYYY)
  50. Any Behaviors or Mental Health Diagnosis?(*)
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  51. If Yes, Please Indicate Diagnosis
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  52. Is Child Currently on Medication?(*)
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  53. If Yes, Please List Medication
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  54. CYF Number(*)
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  55. MCI Number
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  56. Kinship Family Name(*)
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  57. Kinship Family Address (Include City, State, Zip)(*)
    Please check Kinship Family Address address field: Example: 8350 Frankstown Ave Pittsburgh,Pa,15221
  58. Kinship Family Phone Number
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  59. Kinship Family Email Address
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  60. Birth Father Email Address
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  61. Birth Mother Email Address
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  62. POC Caseworker Name
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  63. POC Supervisor Name
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  64. CYF Caseworker Name(*)
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  65. CYF Caseworker Phone Number(*)
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  66. CYF Caseworker Email Address(*)
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  67. CYF Regional Office(*)
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