Initial Relative Safety Screen



|INITIAL RELATIVE SAFETY SCREEN |

|Michigan Department of Health and Human Services |

| |

|Caseworker Name |Caseworker Phone |MDHHS County or PAFC Name |Date of Home Visit |

|      |      |      |      |

| |

|Child(ren) Names |DOB |Legal Relationship to Prospective Caregiver |Person ID |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|      |      |      |      |

|DEMOGRAPHICS |

|Caregiver(s) Name |Maiden Name, Aliases, AKA |DOB |Date of Central Registry |Date of Criminal History |

| |(if applicable) | |Request |Request |

|      |      |      |      |      |

|      |      |      |      |      |

|Caregiver(s) Address |Caregiver(s) Phone |

|      |      |

|ADDITIONAL MEMBERS OF THE HOUSEHOLD |

|Name |Maiden Name, Aliases, AKA |Relationship to |DOB |Date of Central |Date of Criminal |

| |(if applicable) |Caregiver | |Registry Request |History Request |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|CLEARANCES |

|Conduct the following for all adults in the home: |

|VERIFICATION OF IDENTITY |

|Identity of the relative caregiver must be verified. Examples of acceptable verification of identity include, but are not limited to: |

|Driver’s license. |Identification for health benefits. |

|U.S. Passport. |Voter registration card. |

|State-issued identification. |Wage stub. |

|School-issued identification. |Birth certificate/record. |

| | |

|Any documents which reasonably establish the applicant’s identity must be accepted. If documentary evidence is not readily available, use a collateral contact to verify |

|identity. |

|Has the caregiver’s identity been verified? |

|Yes No |

| | |

|CENTRAL REGISTRY |

| | | |

|An adult in the home is listed as a perpetrator on central registry in Michigan. |

| Yes No |If yes, immediate placement is prohibited. Children may be placed with a relative on central registry upon completion and approval of a DHS-3130A.|

| |Relative Placement Home Study, and a court order; see FOM 72203B, Subsequent Placements. |

| |

| |

| |

| |

|The following adult(s) in the home is listed as the perpetrator on central registry. |

|      |

| |

|OUT OF STATE RESIDENCE |

|An adult in the home has resided in another state. (Central registry and criminal history checks must be requested within 72 hours from all states of residence for the |

|past five years.) |

|Name |State(s) of Residence |Date of Central |Date Received |Date of Criminal |Date Received |

| | |Registry Request | |History Request | |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

|      |      |      |      |      |      |

| |

|MULTIPLE CPS INVESTIGATIONS |

|Date of clearance: |      | |

| | | |

|An adult in the home has multiple CPS investigations wherein he/she is indicated as an alleged perpetrator in the home. |

| Yes No |

| | |

|The following adult(s) in the home has multiple CPS investigations and is indicated as the alleged perpetrator. Placement cannot be made until the multiple CPS |

|investigations assessment is completed and approved by the county director. |

| | |

|MULTIPLE CPS INVESTIGATIONS ASSESSMENT |

|Describe the length of time since last investigation and any services that were provided to rectify the problem(s). |

|      |

| | |

|If services were provided, determine if the individual(s) benefitted and completed services successfully. |

|      |

|Address any risk factors that might impact the safety of the child and describe what protective interventions are currently in place. |

|      |

| | |

|NOTE: Child safety must be assessed during contact with the relative considering this CPS information. |

| | |

| |

|STATE CRIMINAL HISTORY CHECK |

|Criminal history checks must include I-CHAT and Sex Offender Registry and must be completed on every household member. The household member’s (including minors) name and|

|home address must be checked on the sex offender registry. |

| | | |

|I. |An adult in the home has a felony conviction for one of the following crimes: |

| |a. Child abuse/neglect |d. A crime involving violence, including rape, sexual assault or homicide but not|

| |b. Spousal abuse |including other physical assault or battery. |

| |c. Crime against children (including pornography). |e. A physical assault or battery within the last five years. |

| | |f. A drug related offense within the last five years. |

| Yes No | If yes, placement is prohibited. |

| | | |

| |List the adult’s name, offense and date of conviction. |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| | |

|II. |An adjudicated sex offender resides in the home |

| Yes No | If yes, placement is prohibited. |

| | |

|III. |The caregiver(s) or other adult in the home has a conviction for one or more of the following good moral character offenses; see BCAL Pub-673, Good Moral |

| |Character. |

| Yes No | If yes, immediate placement is prohibited. Children may be placed upon completion and director approval of the DHS 3130A, Relative Home |

| |Assessment. |

| |List the adult’s name, offense and date of conviction. |

| | | |

| |      |      |      |

| |      |      |      |

| |      |      |      |

| |Note: Placement is not prohibited but requires further assessment. Placement cannot be made until the DHS-3130A, Relative Home Assessment, is completed and approved|

| |by the county director. |

|SAFETY OF PLACEMENT |

|The worker has observed and verified the following: |

| |Yes |No | |

|1. | | |There are enough beds- there are no more than 2 same gendered related children sharing a bed. If 2 related children share a bed it must be larger |

| | | |than a twin bed. |

|2. | | |The bedrooms have a window that is large enough to be used for egress; finished ceiling: floor-to-ceiling permanently affixed walls, and finished |

| | | |flooring; e.g., carpeted, finished wood. |

|3. | | |The caregiver(s) agrees to follow the behavior management plan developed for each child by the agency, which includes refraining from the use of |

| | | |corporal punishment. |

|4. | | |All entrances/exits to and from the home are unobstructed. |

|5. | | |The conditions of the home meet the child’s health care needs; e.g., child has allergies to smoke and the household is smoke free. |

|6. | | |The home is free from observable health/sanitation risks; e.g., flushable toilets, unsoiled mattresses. |

|7. | | |The home is free from observable safety hazards; e.g., broken windows, exposed wires. |

|8. | | |All cleaning supplies, medicines, and/or any other dangerous chemicals are inaccessible. |

|9. | | |There is an accessible working phone in the home (includes cell phone). |

|10. | | |Basic utilities- water, electricity, heating- are in operating condition. |

|11. | | |The caregiver(s) is able to manage his/her own daily living activities, e.g., preparing meals, housekeeping, shopping for groceries, bathing. |

|12. | | |The caregiver(s) has an adequate support system to help him/her care for an additional member of the household. |

|13. | | |There have been reported incidents of domestic violence or there is a history of domestic violence involving the caregiver(s) or any other household |

| | | |member. |

|14. | | |The caregiver(s) or any other household member has a substance/alcohol concern or has a history of substance/alcohol abuse and/or treatment. |

|15. | | |The caregiver(s) has a mental and/or emotional health condition that would impair his/her ability to provide for the child(ren)’s safety and |

| | | |well-being. |

|16. | | |The caregiver(s) has a physical health condition that would affect the care of the child(ren) in the home or the caregiver(s) receives home health |

| | | |services. (Home health services requires an individual to assist the caregiver with daily living activities.) |

|17. | | |There are weapons and/or ammunition in the home. |

|18. | | |(Only answer if yes to #17) All weapons and ammunition are locked-up in a separate room and inaccessible to children. |

|19. | | |The caregiver is being considered for an infant 0-12 months of age. |

|20. | | |(Only answer if yes to #19) The caregiver has been informed of safe sleep guidelines, was provided the Infant Safe Sleep brochure, and has agreed to |

| | | |follow guidelines of safe sleep practice. |

|21. | | |The benefits of licensure have been discussed with the caregiver and the DHS-972, Foster Home Licensing Requirements for Relative Caregivers has been|

| | | |signed. |

|PLACEMENT CONSIDERATIONS |

|Willingness |

|Describe the quality of the relationship between the child(ren) and the caregiver(s). |

|      |

|Describe the caregiver’s willingness to work with parents and follow the treatment plan (visitation, counseling, other identified services, etc.). |

|      |

|Describe the caregiver’s willingness to provide long-term placement, if necessary. |

|      |

| |

|Financial and Employment Status |

|Describe the caregiver’s source of income, including the income type (SSI, RSDI, Unemployment Benefits, etc.) or employer, the amount, and the frequency at which it is |

|paid. |

|      |

| |

|Transportation |

|Describe the caregiver’s means of transportation. Document verification of the caregiver’s driver’s license, auto insurance, and access to required safety seats. |

|      |

|Day Care or Substitute Care |

|Describe the plan for day care or substitute care, include the name and contact information of the alternate care provider. |

|      |

|PLACEMENT RECOMMENDATION |

|Is placement prohibited due to information from the CPS, central registry, or criminal clearances? |

| Yes No | |

| |

| |

|Were there any Safety of Placement concerns identified? |

| Yes No | |

|If yes, please list the identified concerns below: |

|      |

|Do the Safety of Placement concerns prohibit placement? |

| Yes No | |

|If no, list the action to be taken to address the safety concerns and the anticipated date of completion. |

|      |

|Do you recommend this caregiver for placement? |

| Yes No | |

|If no, provide explanation: |

|      |

| |

| |

| By signing below, I acknowledge my home had an initial safety assessment and the caseworker has reviewed the findings with me. |

| |Caregiver(s) Signature |Date | |

| |

| |Signature of Caseworker |Date |Signature of Supervisor |Date | |

| |

| |Director Signature |Date | |

| |

| |

|The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, |

|color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download