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CD-86 SUPERVISED VISITATION CHECKLIST FORM INSTRUCTIONS FOR COMPLETION Purpose The Supervised Visitation Checklist CD-86 was developed to document the interaction between a child and his/her parents siblings and other significant relationships during a visit. The form is optional for staff* Visitation information should be entered into FACES* If the visit is supervised by someone other than the worker such as the resource provider or therapist the form should be completed by the individual supervising the visit. This form is to be placed in the case record as a part of the official case file. When more than one child is present at the visit only one completed CD-86 is needed for the entire family. Completion Section A Case Name Provide the case name. Date Provide the date of the visit. Begin Time Provide the time that the visit started* End Time Provide the time that the visit ended* Child ren s Name Provide the name of the child ren that participated in the visit. Location Print the location/address of the visit. Visit Supervisor Provide the name of the person supervising the visit. Case Manager Provide the name of the assigned case manager. Name of Person s visiting and relationship to child Provide the names of person s visiting the child and their relationship to the child. Section B Check If Applicable Place a check in the checkbox for the listed categories observed demonstrated and communicated during the visit. Section C Comments Please provide and/or note any observations of and/or communications with persons participating in the visit that may be essential to the safety well-being and permanency of the child ren. Overall thoughts on the visits should be provided in the comment box as well* Memoranda History CD06-50 CD12-01 1/12. The form is optional for staff* Visitation information should be entered into FACES* If the visit is supervised by someone other than the worker such as the resource provider or therapist the form should be completed by the individual supervising the visit. This form is to be placed in the case record as a part of the official case file. When more than one child is present at the visit only one completed CD-86 is needed for the entire family. This form is to be placed in the case record as a part of the official case file. When more than one child is present at the visit only one completed CD-86 is needed for the entire family. Completion Section A Case Name Provide the case name. Date Provide the date of the visit. Begin Time Provide the time that the visit started* End Time Provide the time that the visit ended* Child ren s Name Provide the name of the child ren that participated in the visit. Completion Section A Case Name Provide the case name. Date Provide the date of the visit. Begin Time Provide the time that the visit started* End Time Provide the time that the visit ended* Child ren s Name Provide the name of the child ren that participated in the visit. Location Print the location/address of the visit. Visit Supervisor Provide the name of the person supervising the visit.

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