PARENTAL VISITATION DOCUMENTATION FORM Page 1 of 2 Date: __________ Place of Visitation: ______________________________ Address: _______________________________________ List of all who were present: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I arrived at _____:______ am/pm My children was already there. yes/no My children arrived at ____:____ am/pm Others arrived at _____:______ am/pm Description the conditions: My children arrived in or by __________________________________________; Children dressed appropriately for weather? yes/no Children dressed according to family cultural norms? yes/no Children clean? yes/no Marks or bruises seen on children? yes/no Any other comments on the condition of the children: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Details of all interactions between children and me: ie: book reading, diaper changing, food consumed, etc. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ (Everything should be clearly detailed.) Description of child's behavior upon termination of the visit: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ PARENTAL VISITATION DOCUMENTATION FORM Page 2 of 2 Concerns about things said/done during the visit: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ I the undersigned attest that the above foregoing is true and actuate. _______________________________________ Date: ______ Other Witness Signatures: _______________________________________ Date: ______ _______________________________________ Date: ______ _______________________________________ Date: ______ ------------------------------------------------------------------------------- Dear (caseworker) ___________________________, If your version of events varies from mine in any way, please outline specifically any discrepancies you may find in writing within 10 days and summit that copy to me. Sincerely, __________________________________ CERTIFICATE OF SERVICE THE UNDERSIGNED CERTIFIES THAT A FORGOING COPY OF THIS LETTER WAS DELIVERED BY MEANS OF THE FOLLOWING CHECKED BELOW: Hand Delivered / By US Mail / Faxed By Phone _________________________________ Date: ________ Signature of Delivering Party