Georgia Department of Human Resources - GA+SCORE



State of Georgia Division of Family and Children ServicesInitial Family Evaluation Approval Checklist Family Assessor Name: FORMTEXT ?????County/ CPA: FORMTEXT ?????Primary Caregiver Name: FORMTEXT ?????Secondary Caregiver Name: FORMTEXT ?????Other Adult Household Member Name: FORMTEXT ?????Other Adult Household Member Name: FORMTEXT ?????Family Type: FORMCHECKBOX Partnership Parent FORMCHECKBOX Resource Parent FORMCHECKBOX Adoptive Parent FORMCHECKBOX Adoptive Parent Legal Risk If for an identified child(ren), Name: FORMTEXT ????? County: FORMTEXT ?????Information Session Date: FORMTEXT ?????IMPACT Trainers: FORMTEXT ????? FORMTEXT ?????Pre-Service Training Start/End Dates: FORMTEXT ????? Duration in Days or Weeks: FORMTEXT ?????1st HV Date: FORMTEXT ????? 2nd HV Date: FORMTEXT ?????3rd HV Date: FORMTEXT ?????Safety Screening ResultsConfirmationCommentsCriminal Records Check FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AGA DFCS CPS Checks FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AAdam Walsh CPS Checks FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/APardons and Parole FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ADepartment of Corrections FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASex Offenders Registry FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AAccurint Screen FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASUCCESS Screen FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AFamily Evaluation Narrative ComponentsConfirmationCommentsA. Motivation FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AB. Prior Service History FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AC. Caregiver History FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AD. Family Interaction FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AE. Home Environment FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AF. Employment and Income FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AG. Separation and Loss FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AH. Caregiver Protective Capacities FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AI. Partnership Parenting FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AJ. Behavior Management and Discipline FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AK. Child Supervision and Childcare FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AL. Partnership with DFCS FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AM. Continued Parent Development Plan FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AN. Caregiver Placement Preferences FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AO. RecommendationVerificationsConfirmationCommentsMedical Evaluation FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ADrug Screen FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACitizenship FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ADriver’s License/Insurance FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AMarriages, Divorces & Deaths FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AIncome Verification FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASmoke Alarms FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACarbon Monoxide Detector FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AABC Rated Fire Extinguisher FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/APet Inoculations FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AFirearms Secured FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AGas / Fuel-Fired Heater FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASwimming Pool FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AWater/Sewage Bill or Environmental Inspection FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AKempt / Free of Hazards Home Environment FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AReferences FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACPR/1st Aid Certification FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACompleted FormsConfirmationCommentsCaregiver Application FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACPS History Request Form FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ALive Scan Application Form FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/APrior Caregiver Service Report FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AHIPAA Form FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AReasons for Fostering Checklist FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AFamily Assessment Questionnaire FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACouples, Single Applicant and Children’s Questionnaire as applicable FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASafety & Quality Standards Acknowledgement FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACaregiver Reference List FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ARelease of Information FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AAvailable Time Scale FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AAlcohol Use Disorders Identification Test FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASocial Readjustment Rating Scale FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ASensitive Issues Inventory FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AFoster Parent Role Performance Scale FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AReceptivity to Birth Family Connections FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ACultural Receptivity Scale FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/ABriefly State Summary & Recommendations: FORMTEXT ?????Confirmation Statement: The applicant (s) was/were evaluated and found to (meet FORMCHECKBOX not meet FORMCHECKBOX ) the Safety and Quality Standards and all approval requirements. Family Assessor Signature: FORMTEXT ?????Date: FORMTEXT ????? Supervisor Signature: FORMTEXT ?????Date: FORMTEXT ?????County/CPA Director or Designee Signature: FORMTEXT ?????*Date: FORMTEXT ????? FORMCHECKBOX Approved FORMCHECKBOX Not Approved* Date of Approval is the date the evaluation is approved and signed by the director or designee. ................
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