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|[pic] |Tennessee Department of Children’s Services |

| |Resource Home File Section Sheets |

DIRECTIONS:

1. ALL RESOURCE HOME SECTION SHEETS SHOULD BE COPIED AND PLACED IN EACH RESOURCE HOME FILE IN ORDER. THERE SHOULD ONLY BE ONE RESOURCE FAMILY COVER SHEET CS-0675 WITH THE MOST CURRENT INFORMATION. ALL OLD COVER SHEETS SHOULD BE REMOVED FROM THE FILE.

2. EACH SECTION SHEET SHOULD BE SLIPPED INTO A PLASTIC SLEEVE AND PLACED IN FRONT OF EACH SECTION.

3. FILING BEHIND EACH SECTION SHOULD FOLLOW THE ORDER ON THE SHEET.

4. EXTRA OR DUPLICATE DOCUMENTS, ITEMS IN FILE FLAPS BOTH IN FRONT AND AT THE BACK OF THE FILE SHOULD BE REMOVED AND FILED WITHIN THE RESOURCE HOME FILE OR DESTROYED.

5. RESOURCE HOME RECORDING-PRINT RECORDINGS FROM TFACTS WHEN REQUESTED BY REGIONAL MANAGEMENT OR WHEN THE RESOURCE HOME FILE IS SELECTED FOR AUDIT. ONLY USE THE FORM CS-0709 WHEN TFACTS IS INOPERABLE OR INACCESSIBLE.

6. FORMS AND VERIFICATION SECTIONS - FILING SHOULD BE COMPLETED IN THIS MANNER:

ALL SAME FORMS SHOULD BE GROUPED TOGETHER WITH THE MOST RECENT

COMPLETED FORM ON TOP WITH SUBSEQENT YEARS BEHIND. EXAMPLE: DISCIPLINE POLICIES WILL BE GROUPED TOGETHER WITH THE MOST RECENT ON TOP.

7. BACKGROUND CHECK SECTION - EACH PERSONS COMPLETED CHECK (LAW ENFORCEMENT CHECK, INTERNET CHECK, AND DATABASE RESULTS) SHOULD BE CLIPPED TOGETHER (STAPLED OR CLIPPED), SO AS NOT TO GET MIXED UP WITH OTHER ADULT BACKGROUND CHECKS. FINGERPRINT CARDS AND RESULTS SHOULD BE LAST.

8. FISCAL SECTION – EACH MONTHLY INCOME AND EXPENDITURE FORM SHOULD BE FILLED OUT COMPLETELY AND SIGNED AND DATED BY THE RESOURCE PARENT, FSW, AND SUPERVISOR. PROOF OF INCOME SHOULD FOLLOW THIS FORM AND MATCH WHAT IS WRITTEN. THIS SECTION SHOULD HAVE MOST RECENT YEARLY INCOME INFORMATION ON TOP.

9. NEATNESS IS A PRIORITY, MAKE SURE ALL THREE-HOLE PUNCHERS ARE SET THE SAME SO AS NOT TO HAVE PAGES WITH DIFFERENT HOLES. USE HOLE REINFORCERS WHEN NECESSARY. SOILED OR MESSY PAGES SHOULD BE RETYPED AND PLACED IN THE FILE.

10. ALL CASE RECORDINGS SHOULD BE TYPED, SIGNED AND DATED.

11. FAMILY AND EXTERIOR OF HOME PHOTOGRAPHS SHOULD BE FIXED TO PAPER AND PLACED IN A PLASTIC SLEEVE IN ORDER TO PRESERVE THEM. THIS SHOULD BE UPDATED WHEN FAMILY COMPOSITION CHANGES AND WHEN THE FAMILY MOVES TO A DIFFERENT HOME.

Home Study and Reassessments

• Resource Home Cover Sheet – CS-0675 (always on top)

• Resource Home Study Mutual Re-Assessment, Re-Activation or Re-Classification – CS-0692

• Home Study Addendums/Updates (If applicable)

• CS-0961 Resource Family Home Study

• Profile of Parenting Study Tool

• Expedited Placement Assessment Summary – CS-0682 (If applicable)

• Previous or other agency studies

Resource Home Recording

Include documentation of all successful and attempted

contacts and correspondence with resource parents.

◆ Resource Home Recording – CS-0709

• Use form only when TFACTS is in accessible or inoperable

Background Checks

(For all adults in the home)

◆ Criminal History and IV-E Eligibility Checklist – CS-0687

Note: See DCS Policy 16.8, Responsibilities of Approved Resource Homes for additional information.

*National Sex Offender Registry

*Abuse Registry –

◆ Database Search Results – CS-0741

◆ Fingerprint Card Information – CS-0691

◆ Fingerprint Results

◆ Waiver of Criminal Convictions, PATH Training Modifications, Non-Safety Issues, and CPS Indications-CS-0921

Forms

• Resource Home Application for Parenting – CS-0688

• Resource Home Disclosure Acknowledgement, CS-0932

• Authorization for Release of Information to the Department of Children’s Services and Notification of Release – CS-0668

• Home Safety Checklist – CS-0676

• Resource Home Disaster Plan – CS-0871

• Resource Parent Medical Report – CS-0678

• Medical Self Report (Annual) Resource Parent/Child – CS-0707

• Child’s Medical Record – CS-0427(for all birth/adopted children in the home)

• HIPAA Notice of Privacy Practices- Client Acknowledgement- CS-0699

• Resource Parent Oath to Abide – CS-0670

• Disclosure Statement – Options and Available Services for Relative Caregiver Services – CS-0660 (when applicable)

• Discipline Policy – CS-0553

• Family Eco-Map – CS-0782

• Resource Family Strengths/Needs – CS-0895

• AdoptUSKids Information Acknowledgement- CS-0950

Verification

• Birth Certificate (for all household members)

• Valid Drivers License

• Current Proof of Auto Insurance

• Current Auto Registration

• Driving Record Check

• Current Pet Vaccination

• Current Marriage Certificate

• Divorce Decree (for all previous marriages)

•

Death Decree (for any immediate family members)

• Final Decree of Adoption (required for adoption)

• Medical Insurance (required if/when identified as pre-adoptive)

• Contingency Plan

Financial/Fiscal Information

• Monthly Family Income and Expenditures – CS-0431

• Proof of all reported sources of income

• Substitute W-9 – CS-0842

• Special or Extraordinary Rate Request – CS-0674 (if applicable)

• Supplemental Respite Billing – CS-0656 (if applicable)

• Standard Claim Invoice – CS-0493 (with receipt copies)

• ACH (Automated Clearing House) Credits (Not Wire Transfers) – FA-0825

• Voided Check

Placement Contracts

• Expedited Child Placement Contract – CS-0626 (if applicable)

• Daily Rate Child Placement Contract Between DCS and Resource Parents Approved to Provide Temporary Care – CS-0565

• Resource Home Placement Checklist – CS-0544

Training

• PATH Completion Certificate

• Medication Administration Training

• CPR and First Aid Non-Certified Training or

CPR/First Aid Certification

• Core and In-Service Training Completion Certificates

Incident Reports/Corrective Action Plans

• Incident Reports

• Complaint Letters/Memos

Resource Home Corrective Action Plan – CS-0909

• Incident Debriefing- CS-0890

• Special Investigations Notice of Initiation and Closure, CS-0826

Correspondence

• Resource Home Approval – CS-0702 (initial and annual re-approval)

• Denial/Closure Letter (if applicable)

• Other Letters, Notices or written correspondence

• Interstate Compact on the Placement of Children (ICPC) Documents (if applicable)

• Placement of Children Request (100A) – CS-0525

• Report of Child’s Placement Status (100B) – CS-0523

• Interstate Compact on Juveniles (ICJ)Documents (if applicable)

Miscellaneous

• Family Photograph

• Photo of Exterior of the Home

• CS-0962 Resource Family History Questionnaire

• PATH In Review Homework

• Family Home Floor Plan (indicating fire escape route)

• Authorization for DCS Custodial Child to Travel Out-of-State/Out-of-Country – CS-0679 (if applicable)

• Shared Home Authorization- CS-0672 (if applicable)

• Miscellaneous Work Aid Documents (if applicable)

• Resource Family Reference Letter and Questionnaire, CS-0963

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