HOMESTUDY CHECKLIST FOR _________________________________FAMILY

(Please note that this is a general checklist form. Not all applicants will need to complete every block to meet approval/licensing standards. Applicants/assessments will vary depending on individual situations.)

Assessor/social worker name:

Agency:

Agency address and phone #:

E-mail address:

DATES:

___/___/____ Date Application Received by Agency

___/___/____ Date of Initial Social Worker/Assessor Contact

___/___/____ Tennessen warning provided

___/___/____ Foster parent agreement (Foster Care only)

___/___/____ Date of foster care license is effective/adoption study is approved

ORIENTATION AND/OR
TRAINING COMPLETED

 

List Dates(s)

List Topic(s) Covered

Number of Hours

How Delivered

Applicant #1

       

Applicant #2

       

___/___/____ Date Assessment Visits Completed

Date of Visit

Names(s) of those present

Where visit occurred

 

Date of Visit

Name(s) of those present

Where visit occurred

             
             
             
             

DATES COMPLETED:

Reference:

Received 3 references:

     

Documentation of health assessment for all household members:

     

Background Studies

___/___/____ Date Initiated: Background studies have been conducted on all individuals for whom a background study is required pursuant to Minnesota Statutes, section 245A.04, subd. 3 (6) (c).

Household Member

       

Intake/Soc. Service

       

BCA

       

Juvenile Court

       

Do any of these background checks contain information that would disqualify the applicants or household members? ?

o Yes o No

If Yes, explain:___________________________________________________________

Date issues discussed with applicant ___/___/____

*Minnesota does not have a state child abuse registry.

Do any of the verifications (except the homestudy visits) contain information that would cause limitations/restrictions regarding the care of a foster or adopted child?

o Yes o No

If Yes, explain:___________________________________________________________

Date issues discussed with prospective applicant Applicant1

Adoption Specific Requirements:

___/___/____ Verified Marriage How Verified:

___/___/____ Verified divorce How Verified:

Home Safety:

___/___/____ Home safety checklist (Foster Care only)

___/___/____ Fire inspection (Foster Care only, if required)

___/___/____ Water test completed (if required)

___/___/____ Alternative Water Plan submitted/approved (foster care only)

Update/Relicensing:

___/___/____ Placement evaluations sent to provider Date received: ___/___/____

___/___/____ Placement evaluations sent to case manager Date received: ___/___/____


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