CPS POLICY HOME STUDY REVIEW AND CHECKLIST (1/06)
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Foster to Adopt Home Development Checklist
( Kinship/Fictive Kinship Foster to Adopt ( Unrelated Foster to Adopt
Family Name: _____________________________________________________________________ Email Address: ______________________________________
Home Address: ___________________________________________________________________ City: _______________________ Zip: _________________
Home Phone: ___________________________ Caregiver 1 Cell: _______________________ Caregiver 2 Cell: ____________________________________
Foster to Adopt Orientation Date: _________________ (Note: 90-day period for Kinship/Fictive Kinship Home Completion / 120-day period for Unrelated Foster to Adopt Home Completion)
STEP 1: PRE-QUALIFICATION (Please attach all documents)
|Application – This section must be completed prior to submitting Background Checks. The process must stop if the application is not complete. |
|___ Prospective Foster to Adoptive Family Inquiry |
|___ Foster to Adoptive Application - (Completed and signed) |
|___ Kinship Foster to Adopt (Consent for Release of Information from DFPS Kinship Worker) |
|___ DFPS Kinship Assessment |
|___ Foster to Adoptive Family (Consent for Release of Information from previous CPA) If, applicable |
|___ Foster to Adopt Family Transfer Requirements Acknowledgement / Agreement Form |
|___ Previous CPA Home Study (if applicable) |
|Background Checks – This section must be completed prior to conducting the initial home pre-verification inspection. |
|___ Caregiver #1-SHCS Criminal History/ Central Registry Check Consent Form (Class I Abuse Statement) ____________________________ Name |
|___ Caregiver #1-FAST Fingerprint Receipt |
|___ Caregiver #1-Background Check Results: DFPS |
|___ Caregiver #1-Background Check Results: DPS |
|___ Caregiver #1-Bacground Check Results: FBI |
|___ Caregiver #1-Out-of-State Central Registry Request Form |
|___ Caregiver #1-Out-of State Central Registry Results |
| |
|___ Caregiver #2-SHCS Criminal History/ Central Registry Check Consent Form (Class I Abuse Statement) ____________________________ Name |
|___ Caregiver #2-FAST Fingerprint Receipt |
|___ Caregiver #2-Background Check Results: DFPS |
|___ Caregiver #2-Background Check Results: DPS |
|___ Caregiver #2-Bacground Check Results: FBI |
|___ Caregiver #2-Out-of-State Central Registry Request Form |
|___ Caregiver #2-Out-of State Central Registry Results |
|___ Biological Children residing in the home (who are 14 yrs. of age) – SHCS Criminal History/Central Registry Check Consent Form (Class I Abuse Statement) |
|__________________________Name |
|___ FAST Fingerprint Receipt |
|___ Background Check Results: DFPS |
|___ Background Check Results: DPS |
|___ Background Check Results: FBI |
|___ Out-of-State Central Registry Request Form |
|___ Out-of State Central Registry Results |
| |
|___ Other resident age 14 or older-SHCS Criminal History/Central Registry Check Consent Form (Class I Abuse Statement) _______________________________ Name |
|___ FAST Fingerprint Receipt |
|___ Background Check Results: DFPS |
|___ Background Check Results: DPS |
|___ Background Check Results: FBI |
|___ Out-of-State Central Registry Request Form |
|___ Out-of State Central Registry Results |
|Home Pre-verification Inspection – This section must be completed prior to proceeding to STEP 2. If the home possesses any deficiencies the process must stop until|
|all deficiencies are corrected. |
|___ Initial Environmental Health Checklist (Local Health Department Letter attached) |
|___ Residential Child-Care Licensing approved variance (if applicable) |
|___ Initial Fire Safety Prevention Checklist |
|___ Criminal Background Unit approved risk assessment (if applicable) |
|___ In-Home Orientation |
|___ Kinship Assessment |
|Domestic Violence Check |
|___ Domestic Violence Statement Signed by both Foster to Adopt Parents |
|___ Domestic Violence Call History from Local Police Department (26 Months for all previous addresses within this time period) |
____________________________ __________/ _______________________________ ___________/ _____________________ _________________
F.D.S. (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date
STEP 2: COLLECTION OF PERSONAL DOCUMENTS (Please attach all documents)
|Personal Identification, Financial, Marital Status and Education |
|Name: ________________________ |
|___ Caregiver #1-Texas driver’s license |
|___ Caregiver #1-Birth Certificate |
|___ Caregiver #1-Social Security Card |
|___ Caregiver #1-Education (Diploma, Transcripts, or G.E.D) or Foster to Adopt Proficiency Evaluation |
|___ Caregiver #1-Income verification: must include (60 days of paycheck stubs, 2 months of bank deposit statements, and previous year W-2 statements) |
|___ Caregiver #1-Divorce Decree or Death Certificate from all previous marriages |
|___ Caregiver #1-Affidavit signed and notarized |
| |
|Name: ________________________ |
|___ Caregiver #2-Texas driver’s license |
|___ Caregiver #2-Birth Certificate |
|___ Caregiver #2-Social Security Card |
|___ Caregiver #2-Education (Diploma, Transcripts, or G.E.D) or Foster to Adopt Proficiency Evaluation |
|___ Caregiver #2-Income verification must include: (60 days of paycheck stubs, 2 months of bank deposit statements, and previous year W-2 statements) |
|___ Caregiver #2-Divorce Decree or Death Certificate from all previous marriages |
|___ Caregiver #2-Affidavit signed and notarized |
| |
|___ Marriage Certificate (current marriage) |
|___ Birth Cert. for all household members |
|___ Other-Affidavit signed and notarized (all household members 14yrs & older) |
|___ Family’s Financial Contingency Plan for the child(ren) being adopted: Life Insurance Policy, Will, Trust-Fund and/or Other Beneficiary Policy (if, applicable)|
|Written References |
|___ 3 Non-Relative Community (i.e. neighbors, school personnel, clergy, or other unrelated person from the community) |
|___ 2 Relative (not including biological child) |
|___ Biological Children age 12 and over not living in the home |
|Health Screening |
|___ Caregiver #1-Health Statement |
|___ Caregiver #1-TB test |
|___ Caregiver #2-Health Statement |
|___ Caregiver #2-TB test |
|___ TB tests for all children(including child age 1) and other adult household members |
|Home Description/View |
|___ External view of home (photos of foster child bedrooms, front, sides, and back yard; including out houses, sheds, other structures and play equipment) |
|___ Floor plan with all room dimensions and usage (including emergency evacuation routes) |
| |
|Home Safety & Equipment |
|___ Photo of Foster Care OMBUDSMAN Poster: Posted in the Foster Home |
|___ Photo of First-Aid Kit |
|___ Photo of Medication Storage (Double Locked System) |
|___ Photo of Fire Escape Ladder (2 Story Homes or Second Story Apartment Units ONLY) |
|___ Photo of Fire Extinguisher (5lbs) one for each level (service/tagged is Required) |
|___ Photo of Fire Evacuation Route Posted in each child’s bedroom |
|___ Photo of Child Safety Kit install if, fostering infants to 8 years old. (i.e. lower cabinets, electrical covers, stair gate, and bathroom door knobs) (if, |
|applicable) |
|___ Photo of Home/Apartment Complex Swimming Pools or any standing body of water, lake, pond, etc. (must be secured with a 4 ft. fence around it) including |
|exit-door chime |
|___ Photo of Water Safety Rescue Equipment (life raft, life vest and pool pole) |
|___ Photo of Outdoor Hot Tub (must be secured with a 4 ft. fence around it or must be equipped with lid and lock when not in use) |
|___ Photo of Mattress Covers placed on each child’s mattress (plastic cover is required for a child who wets the bed) |
| |
|Home Inspections |
|___ Local Health Department Service Letter of Denial (must be from the current year of development) |
|___ Local Health Department Foster Home Inspection (if required by Local Health Department) |
|___ Final Environmental Health Checklist (not required if, there were no deficiencies found during the initial inspection and maintained compliance during |
|development) |
|___ Fire Inspection by Local Fire Marshall (not accepting fire inspection performed by an unauthorized Fire Marshall) |
|___ Gas Pressure Test (if, applicable) |
| |
|Fire Arms, Explosive Materials, and Projectiles Safety & Inspections |
|___ Weapons Safety Documentation Form (completed & signed by all adults residing in the home) |
|___ Photo of Weapons, Fire Arms, Explosive Materials, and Projectiles Stored and Locked (if, applicable) |
|___ Photo of Ammunition Stored Separately from Weapon (if, applicable) |
| |
|Auto |
|___ Auto Insurance (all vehicles used to transport children) |
|Pets |
|___ Pet vaccinations (if, applicable) |
|Frequent Visitors/Temporary Residents |
|___ Frequent Visitor/Temporary Resident (who are 14 yrs. of age or older)-Criminal History/Central Registry Check Consent Form (Class I Abuse Statement) |
|___ Background Check Results: DFPS |
|___ Background Check Results: DPS |
|___ Background Check Results: FBI (if, lived outside of Texas within the past 5yrs) |
|___ Frequent Visitor/Temporary Resident Approval Letter and/or ____ Restricted Persons Letter (If, applicable) |
____________________________ __________/ _______________________________ ___________/ _____________________ _________________
F.D.S. (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date
STEP 3: PRE-SERVICE TRAINING (Please attach all documents)
|Caregiver #1Training |
| |
|Name:______________________________________ |
|Instructor Led Training |
|___ Orientation Certificate |
|___ PRIDE 16hrs (including 8hrs of Emergency Behavior Intervention & Normalcy-“Reasonable and Prudent Parenting Standards”) |
|___ Trauma Informed Care 6hrs (including Adverse Childhood Trauma and Prevention of Secondary Trauma “Compassion Fatigue”) |
|___ Integrated Emergency Behavior Intervention & Trauma Informed Care 8hrs (including the use of PAPH) |
|___ CPR (adult, infant & child) & First-Aid 2hrs |
|___ Medication Management & Preventing the Spread of Communicable Diseases 1hr (including SHCS Policy & Procedure) |
|___ Emergency Procedure Planning (including Weather Emergencies DEP & Volatile Persons & Handling Child or Caregiver Emergency |
|Illness Emergencies) 1hr |
| |
|Self-Instructed (On-line) Training |
|___ Psychotropic Medication 2hrs (DFPS website) |
|___ Trauma Informed Care 2hrs (DFPS website) |
|___ Medical Consent Training 2.5hrs (DFPS website) |
|___ Transportation Safety 2hrs (website) |
|___ Reporting Suspected Abuse or Neglect of a Child 1hr (DFPS website) |
| |
|Optional Training (if verified to care for infants to 4 year old toddlers) |
|___ SIDs 2hrs (DFPS website) |
|___ Ensuring the Health and Safety of Infants and Toddlers in care 2hrs (DFPS website) |
|___ Instructor Led Water Safety Training 2hrs (If home or apartment, has a hot tube, pool or standing body of water, lake, pond, etc.) |
|Caregiver #1Training |
| |
|Name:______________________________________ |
|Instructor Led Training |
|___ Orientation Certificate |
|___ PRIDE 16hrs (including 8hrs of Emergency Behavior Intervention & Normalcy-“Reasonable and Prudent Parenting Standards”) |
|___ Trauma Informed Care 6hrs (including Adverse Childhood Trauma and Prevention of Secondary Trauma “Compassion Fatigue”) |
|___ Integrated Emergency Behavior Intervention & Trauma Informed Care 8hrs (including the use of PAPH) |
|___ CPR (adult, infant & child) & First-Aid 2hrs |
|___ Medication Management & Preventing the Spread of Communicable Diseases 1hr (including SHCS Policy & Procedure) |
|___ Emergency Procedure Planning (including Weather Emergencies DEP & Volatile Persons & Handling Child or Caregiver Emergency |
|Illness Emergencies) 1hr |
| |
|Self-Instructed (On-line) Training) |
|___ Psychotropic Medication 2hrs (DFPS website) |
|___ Trauma Informed Care 2hrs (DFPS website) |
|___ Medical Consent Training 2.5hrs (DFPS website) |
|___ Transportation Safety 2hrs (website) |
|___ Reporting Suspected Abuse or Neglect of a Child 1hr (DFPS website) |
| |
|Optional Training (if verified to care for infants to 4 year old toddlers) |
|___ SIDs 2hrs (DFPS website) |
|___ Ensuring the Health and Safety of Infants and Toddlers in care 2hrs (DFPS website) |
|___ Instructor Led Water Safety Training 2hrs (If home or apartment, has a hot tube, pool or standing body of water, lake, pond, etc.) |
|Foster to Adopt Family Training Plan |
|___ Individual Family Training Plan |
|Additional Training (must be completed within 14 days of verification) |
|___ New FP 40hrs of Observation Training |
|Occasional Child-Care Providers |
| |
|Name:______________________________________ |
|___ Attach the Occasional Child-Care Provider Checklist for each caregiver |
| |
|Name:______________________________________ |
|___ Attach the Occasional Child-Care Provider Checklist for each caregiver |
____________________________ __________/ _______________________________ ___________/ _____________________ _________________
F.D.S. (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date
STEP 4: VERIFICATION FOSTER TO ADOPT HOME INTAKE (Please attach all documents)
|Verification |
|___ Foster to Adopt Home Study |
|___ Agency Verification |
|___ RCCL Form 2953 Foster Home Registration (enter in DFPS Website) |
|___ RCCL Agency Home License (retrieve from DFPS Website) # ______________________ |
|Other Required Documents |
|___ Home Rules |
|___ Discipline Plan |
|___ Discipline Policy-signed |
|___ Health Care Providers List (Approved STAR Health Providers only) |
|___ List of local Schools |
|Foster to Adopt Home Agreement |
|___ Statement of Foster to Adopt Parent and CPA Rights and Responsibilities DFPS form 3001 |
|___ Foster to Adopt Home Agreement |
|___ Reporting Abuse and Neglect Policy |
|___ Confidentiality Statement |
|___ Corporal Punishment policy |
|___ Appeals Process for Agency Clients |
|___ Security Policy for the Client Information System & E-mail |
|___ Foster Care Ombudsman Poster |
|___ Foster Care Ombudsman Acknowledgement Letter |
|Mis. |
|___ Foster to Adopt Parent Annual Training Schedule |
|___ DFPS Medical Transportation Program Letter (signed by both Foster Parents) |
|___ Direct Deposit (Optional) |
|___ Emergency/Disaster Policy |
|___ Foster to Adopt Parent Hand Book Review Confirmation |
|___ THSTEP Brochure “Acknowledgement of Receipt” |
|___ DFPS Campaign to Curb Infant Sleeping Deaths (if, applicable) |
|___ See and Save |
|___ Watch Kids Around Water |
|___ Water Safety Policy (if, applicable) |
|___ Water Safety Plan (if, applicable) |
|___ Foster to Adopt Home Water Safety Rules (if, applicable) |
|Child Initial Services |
|___ Child’s DFPS Service Plan |
|___ Physical Exam (must be current within the current calendar year or according to the THSTEP Chart) |
|___ Hearing Exam for children age 3 and up (must be within 12 months of placement) |
|___ Vision Exam for children age 3 and up (must be within 12 months of placement) |
|___ Dental (must be within 12 months of placement) |
|___ TB Exam (must be within the calendar year) |
|___ Current Immunization Record |
|This section is for Foster to Adopt and Kinship-Foster to Adopt Homes Only |
| |
|__ Foster to Adopt Home Compliance Binder |
_________________________________ __________/ _______________________________ ___________/ _____________________ _________________
Program Manager (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date
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