Relative Care Assessment

A. Date Section: 1. Date Evaluation Initiated: 2. Identify Child: 3. Relative Name and Spouse: 4. Relative's Relationship to the Child: 5. Reason for Evaluation: 6. Household Composition (names, ages, gender, relationship to the child and other household members): 7. Prior DFCS Involvement (relative caregiver and all household members):

B. Domains and Areas Evaluated: Include interpersonal relationships between parent and child/between parent and relative caregiver(s)/between relative's caregiver(s) and child, interpersonal relationships with the child(ren)being placed/with other household members, household members/key data, living arrangements, sleeping arrangements, employment history, current financial status, health history/current status(all family members), marriage status, discipline views and practices, corporal punishment views and practices, commitment to abide by state prohibition of corporal punishment, practices and views on maintaining parental/sibling/other family ties, history of criminal activity, residence check, drug screening, and medical statement. (Attach criminal activity, GCIC, NCIC, residence check, drug screening and medical reports)

C. Home Environment: Include appearance and state of repair/maintenance issues, cleanliness, soundness of physical dwelling, appearance of electrical wiring system/fixtures/outlets, appearance of gas lines/heating/cooking appliances, availability and condition of running water indoors/toilet facilities indoors, appearance of household furnishings, availability and appearance of storage facilities (closets, cabinets, pantry, bookshelves, etc.), and availability of working smoke alarms inside the house.

D. Home and Personal Safety Issues, Practices and Concerns: Include swimming or wading pools/ponds/lakes/etc., trampolines, animals, environmental hazards, weapons, electrical wiring, waste (garbage, trash, animal feces, etc.), unlocked and inoperable vehicles/appliances/etc., dangerous porches/steps/doors/etc., inadequate fencing, and access to busy streets and/or highways. (Attach swimming, weapons policy agreements)

E. Views and Practices of Child Supervision: Include swimming or wading pools/ponds/lakes/etc., trampolines, animals, environmental hazards, weapons, electrical wiring, waste (garbage, trash, animal feces, etc.), unlocked and inoperable vehicles/appliances/etc., dangerous porches/steps/doors/etc., inadequate fencing, and access to busy streets and/or highways.

F. Explore: Include family/community resources, birth/extended family's strengths/needs, sleeping arrangements, operable telephone emergency numbers posted or in reasonable access to the telephone, family own a vehicle (if not, describe the mode of transportation), is liability insurance current?, valid driver's license, required child restraint devices available, is relative employed?, does relative own/rent residence?, are there provisions in the lease for the relative to move another person in the home?, etc. (Attach lease/mortgage contract)

G. References: Two references required.

H. Other: Include additional pertinent observation/concerns (must be discussed), factors should be considered in a determination for placement with relative caregiver according to CCFA/initial case plan, and information from FTM and MDT may be included in this assessment. I. Results of Evaluation: Include findings and conclusions.

J. Summary and Recommendations:

Complete name(s), signature(s), titles and dates on all required documents and/or forms.

Case Manager: Date: County DFCS Telephone: