CHILD PROTECTIVE SERVICES’ NOTICE OF DUTY TO INFORM

PS-045 (9-07) ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Children, Youth and Families
CHILD PROTECTIVE SERVICES’ NOTICE OF DUTY TO INFORM
When Child Protective Services (CPS) receives an allegation of child abuse or neglect by a parent, guardian or custodian
and a report is taken, Arizona law requires CPS to conduct an investigation and provide you with information about your
rights both verbally and in writing. The following complaint or allegation concerning your family is currently under
investigation:
This notice is to inform you that:
• CPS has no legal authority to compel or make you cooperate with the investigation or to accept services, but it is our
hope that by working together we can find solutions to ensure that your child (or children) is safe and that your family
has what it needs.
• CPS has a duty to proceed with the investigation even if you decide not to cooperate to ensure that your child (or
children) is safe, although we would prefer to carry on with the investigation with your support.
• Your refusal to cooperate with the investigation or services offered does not in itself form a basis for CPS to take
temporary custody of your child (or children), unless it is clearly necessary to protect your child (or children) from
abuse or neglect.
• CPS has the authority to petition the Juvenile Court for a determination that your child (or children) is dependent and in
need of protection.
• You have the right to provide written, telephonic or verbal responses to the allegation, including any documentation,
and to have the information considered in determining whether your child (or children) is in need of protective services.
• You need to know that anything you say or write can be used in a court proceeding.
• You need to know that anything you say may be included in CPS’ report of the investigation.
• You need to know that any written response that you provide, including any documentation, will be included in the
CPS case record.
• You need to know that any information that you provide in response to the complaint or allegation(s) will be
considered during the investigation.
• You have the right to appeal determinations made by CPS about the results of the investigation and will be notified in
writing of these results and how to appeal.
• You have the right to:
• Request and participate in a Mediation Program in the Attorney General’s Office. The telephone number for the
Mediation Program in Phoenix is (602) 542-7767, and in Tucson, (520) 628-6782. The Mediation Program may be
used to settle disputes that arise among families, CPS, and others concerned with the welfare of children.
• File a complaint with the Arizona Ombudsman-Citizens Aide. The telephone number in Phoenix is (602) 277-7292,
and statewide toll-free is 1-800-872-2879. The Ombudsman-Citizen Aide office is available to handle inquiries,
concerns and complaints about agency actions, including CPS.
More information about CPS and your parental rights are outlined in the pamphlet, “Guide to Child Protective Services”
that I am leaving with you today.
By signing this form, you are acknowledging that I have reviewed the information contained in this notice with you.
PARENT, GUARDIAN OR CUSTODIAN'S SIGNATURE PARENT, GUARDIAN OR CUSTODIAN'S NAME (Please print) DATE
PARENT, GUARDIAN OR CUSTODIAN'S SIGNATURE PARENT, GUARDIAN OR CUSTODIAN'S NAME (Please print) DATE
Yes No Parents were asked about Native American/American Indian heritage.
Explain:__________________________________________________________________________________________
CPS SPECIALIST'S SIGNATURE CPS SPECIALIST NAME (Please print) DATE
See reverse for EOE/ADA disclosure.
Equal Opportunity Employer/Program Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and
the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, and the Age
Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services, activities, or
employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a
reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For
example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a
wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other
reasonable action that allows you to take part in and understand a program or activity, including making reasonable
changes to an activity. If you believe that you will not be able to understand or take part in a program or activity
because of your disability, please let us know of your disability needs in advance if at all possible. To
request this document in alternative format or for further information about this policy, contact 602-542-0220;
TTY/TDD Services: 7-1-1.