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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