Attachment #3 MUST BE ON AGENCY LETTERHEAD HOME STUDY for (Country or Program)

Please Note: Holt requires that all home studies be written in accordance with Hague Convention regulations, regardless of the country’s Hague status. All studies must include all required Hague language as listed in the following outline.

For India: Please review the separate India Home Study Guideline Supplement for more detailed information about additional India specific requirements.

Applicants: List each applicant’s full legal name (no initials) as it appears on birth/marriage certificates Address: City/State/Zip: County: Telephone: Passport numbers: (Korea only)

 Date Prepared:  Prepared by: (social worker’s name, credentials and licensing number and expiration date if applicable) who is employed by (agency name). List state regulations regarding requirements for direct service workers and state licensing regulations. List license number and expiration date if applicable. If license does not have an expiration date, indicate this. Indicate whether agency is a supervised provider and include date supervised provider agreement was signed by Holt.  Add the following statement: This home study is to be used for the sole purpose of an through Holt International Children’s Services, Inc.

Sample wording for SUPERVISED PROVIDERS: “Prepared by (social worker’s name, credentials, and license number and expiration date if applicable,) who is authorized by the State of (list state) to prepare home studies according to (list state statute regarding requirements of social worker who prepare home studies) and employed by(or contract worker for) Children’s Home Society. Children’s Home Society is authorized by the state of (name state and site state regulations that refers to agency licensing) to research and prepare adoption home studies (list license number and expiration date if applicable). Children’s Home Society is a supervised provider for Holt International Children’s Services, Inc. based on an agreement executed on (date supervised provider agreement signed by Holt). In accordance with 22 CFR Part 96, Holt International Children’s Services, Inc. is an accredited agency on file with the Department of State. This home study is to be used for the sole purpose of an international adoption through Holt International Children’s Services, Inc.”

Sample wording for BRANCHES: “Prepared by (social worker’s name, credentials and license number and expiration date if applicable) who is authorized by the state of Oregon to prepare home studies- under ORS 413- 220-0040(4) (a)- 413-220-0040 (4) (g) and is employed by Holt International Children’s Services, Inc. In accordance with 22 CFR Part 96, Holt International Children’s Services, Inc. is an accredited agency on file with the Department of State as having the authority to conduct Convention home studies and is licensed by the Department of Human Services of the State of Oregon under ORS 418.205-418.310, 418.325-418.327, to research and prepare adoption home studies. Oregon does not require home study preparers to hold individual licenses. Holt’s current license #0076 expires October 31, 2014. This home study is to be used for the sole purpose of an international adoption through Holt International Children’s Services, Inc.”

SUMMARY OF AGENCY CONTACTS  Include the date of each visit, where it was held, and who was present for each contact with the family. Include date of application to agency and date home study was referred to social worker.  At least one visit must be conducted in the home.  There must be at least one face to face interview conducted with each member of the household, including children living in the home.  CHINA: four face to face contacts required.

OVERVIEW OF THE FAMILY/MOTIVATION TO ADOPT  Reasons/rationale family wants to adopt in general and from specific country. Generic references to Africa or Asia are not sufficient.  Infertility should be discussed if an issue - particularly how couple has managed loss.  Motivation and openness to adopt a child with special needs – discuss in detail specific conditions/special needs the family is open to accepting. Include a clear statement from the social worker assessing the family’s preparedness and suitability to adopt a child with special needs.  Also discuss parents’ ability to provide for a child with special needs (e.g., health insurance, training, adequate finances, other resources).  Discuss attitude of extended family toward the adoption plans.

ADOPTIVE FATHER  Date of birth, place of birth; including statement that social worker has verified birth certificate.  Naturalized Citizens- U.S. Naturalization Certificate number, date and place of naturalization. Note: If the applicant immigrated, include a summary paragraph noting: 1) Age when immigration occurred, 2) reasons for immigration, 3) significant challenges to the immigration process, 4) adjustments to life in a new country e.g. culture shock, grief and loss, 5) broadness of social interactions outside work, and 6) insights gained from their immigration that may impact their understanding of what child may experience.  INDO-AMERICANS ONLY: U.S. Passport with number, date and place of issue.  Physical description: Height, weight, eye color, hair color, and statement regarding heritage, racial background or ethnicity.  Family background and dynamics: Names of mother, father, siblings, their current residences, occupations, marital status, status of current relationship and knowledge and attitude concerning adoption plans.  Single Applicants: must include applicants appraisal of their unmarried status, expectation/desire to be married in the future, discussion of if/how their attitude toward adopted child will change if they marry, statement that the applicant was asked about their sexual preference and the social worker attests to the veracity of their statement that they are not homosexual.  Education History, including names of colleges attended, time period at each college (what year to what year), name of degree/certificate received, if no degree/certificate earned state this.  Employment History, including name of current employer, position/title held by parent, a description of what type of business or organization it is, and a description of the type of work the parent is responsible for.  Significant Life Experiences. Most influential person; discussion of previous marriage/s, include reasons for divorce, dates, names of previous spouse/s and current relationship with ex-spouse. In the event of previous marriages, the study must include a statement that the social worker has verified the divorce decree or death certificate of former spouse(s).  Health History and social worker’s assessment of applicant’s mental stability. Include a statement that social worker has seen medical report that indicates applicant is free of communicable diseases, including TB & HIV/AIDS. The description of health/medical issues should be consistent with the medical report/Certificate of Health Examination completed by the applicant’s physician for the country program dossier.

2 Sample Wording: “(Name) was examined by his physician on September 1, 2013. He was found to be free of infectious diseases, including HIV/AIDS and tuberculosis. (Name) was found to be of sufficient emotional stability to parent a child. This report was reviewed by this worker and the above findings are as stated. It is this worker’s assessment that (Name) is emotionally, physically and mentally stable and will provide a loving home for any child placed in this family. Under section 8 CFR 204.311(9), no referrals were made to medical or mental health professionals."

registries must be checked in any State or foreign country that a prospective adoptive parent or adult member of the household has resided in since that person’s 18th birthday. If the parent has only lived in one state since the age of 18 and has never lived outside the U.S., please state this. (Note: If a state of residence is missed, it will likely be noted by USCIS. Temporary out of state job assignments or studies may have generated records in government databases that are accessible by USCIS.) Include result of check and list State where check was conducted. If no child abuse check is accessible for a specific state or country, write statement attesting to this and list authority who verified there is no registry.  Result of background criminal history check performed by state; include name of state agency completing check and date completed. State if record was found or not found.  Indicate family was informed of their duty to disclose. Social workers must inform family during the home study process of their duty to provide true and complete information to the home study preparer and the consequences of not disclosing this information. Indicate that applicant was asked each of the following questions and indicate their response: o Have you ever been arrested and fingerprinted, even if the record was sealed, pardoned, or expunged? Note: If applicant answers yes, even if the record was sealed, pardoned, or expunged, or the applicant was a juvenile at the time of the arrest, the incident and the social workers assessment of the applicant’s rehabilitation must be thoroughly discussed and evaluated in the study. o Have you ever received treatment for alcohol abuse? o Have you abused illegal controlled substances or prescription drugs? o Have you ever had any involvement with domestic violence or sexual abuse (even if it did not result in a conviction)? Note: If applicant is the perpetrator, his/her disclosure must be documented in the study. o Do you have a history with child protective services in the U.S. or overseas? o Has Immigration ever refused you visa clearance? o Have you ever been rejected as a prospective adoptive parent? o Have you ever been the subject of an unfavorable home study?

 If family answers YES to any of the questions listed above, the information must be thoroughly discussed and evaluated in the study. Contact Holt Country Program Director to discuss appropriate documentation of issue.

“(Name of prospective adoptive parent) has been informed and understands that under penalty of perjury it is his duty to disclose all information under 8 CFR 204.311(d). (Name) is aware that he must notify the home study preparer and USCIS of any new event or information that might warrant submission of an amended or updated home study and that the duty to disclose is ongoing while form I-800A/I-600A is pending, after form I- 800A/I-600A is approved, and while any form I-800/I-600 is pending until there is a final decision admitting the child to the U.S. on a visa. In response to a direct question from this worker, (Name) states he has disclosed any history of physical, mental or emotional health problems to the home study preparer and that he has no history to disclose –or- and those disclosures have been documented in this home study. (Name) states that he has never initiated a home study process prior to coming to Holt and therefore has never been the subject of an unfavorable adoption home study (if family previously completed home study or you are updating an existing home study, see below). (Name) states that he has never been refused visa clearance by USCIS; never abused alcohol; never used or abused controlled substances; nor has he been a perpetrator of domestic violence, sexual abuse or child abuse, either in the U.S. or abroad.. (Name) states that he has not been the perpetrator of a crime even if it did not result in an arrest or conviction, either in the U.S. or abroad. A Criminal Records Check

3 conducted by (list State authority) dated September 1, 2013, was received and no records were found. (Name) states that he has resided solely in the State of (list state) since the age of eighteen. A Child Protective Services Check conducted by (list state authority) dated August 2, 2013 was received and no records were found. (If applicant has lived outside of their current State of residence since age 18, indicate each State or country of residence, the time period the applicant resided in that location, and the results of the child abuse check for that State or country)”

 If family has completed a home study process previously, the following information must be included in the study: - Date prior home study process began - Name of the home study agency - Date prior home study was completed or terminated - Reason for termination (if any) - Whether the prior home study recommended the applicant or additional adult member of the household as suitable for adoption, , or other custodial care of a child, and whether the a placement of a child occurred.  If you are updating the family’s home study, include a statement indicating when the initial home study was completed. Example: “The (last name) family initiated the process for this home study on (date) and this is an update to that study.”

ADOPTIVE MOTHER Same as Adoptive Father

MARRIAGE  Date and place of marriage, including statement that social worker has verified marriage certificate.  Present marital relationship and patterns of resolving conflict, stress management, strengths, concerns, roles of partners.  CHINA: Must include a statement that the couple is satisfied and/or happy with their marriage.

CHILDREN  Descriptive paragraph of every child (under age 18) residing in the home and relationship to applicants. Discuss any children living out of the home in a separate paragraph.  If any child living in the home turns 18 after the initial study is completed, but before placement of a child for adoption, the study will need to be updated with criminal and child abuse checks for that individual.  Date of birth, physical description, assessment of personality, work or school status. Special needs of children already in the home that may affect placement. State whether children are birth or adopted, agency, process or country if appropriate.  Children under 18 should be interviewed for age appropriate understanding of and support of the adoption plan. Discuss what effect adding a child with special needs will have on each child, if applicable. CHINA: For children over ten years old, include a statement regarding view with regard to their parent(s) adopting a child from China.  (Any related or unrelated person(s) over 18 residing in the home must be included in OTHERS IN THE HOME section.)

4 OTHERS IN THE HOME  In-home day care providers or others with regular ongoing access to the home may be considered household members by USCIS and as such, must be included in this section.  Date of birth, physical description, assessment of personality, work or school status; discuss special needs of individual that may affect the adoptive placement.  Assess individual’s relationship and ability to adjust to child to be adopted. Note: Individuals over age 18 should be asked same questions adoptive applicants were asked regarding substance abuse, sexual or child abuse and domestic violence and whether rejected as adoptive applicants, been subject of unfavorable home study or been refused visa clearance by USCIS, and their responses discussed. Include physical, mental, and emotional capability statement. (see Adoptive Father for example)  Child abuse registries must be checked in any State or foreign country that any adult member of the household has resided in since that person’s 18th birthday. Include result of check and list the state where the check was conducted.  Result of background criminal history check performed by state; include date completed. State if record was found or not found.

PARENTING SKILLS AND VALUES  Philosophies of child rearing and experiences that have influenced their beliefs/behavior. Include discussion of child discipline practices in the family.  Plans for leave of absence from work and how family will accommodate reduction of income.  Childcare plans when/if they return to work.  Attitudes toward adoption, how adoption will be discussed with child, etc.  Statement of applicant’s knowledge and acceptance that a child may be developmentally delayed due to institutionalization.  Indicate whether your state has specific regulations regarding parent preparation and cite those regulations. If there is no state regulations, indicate this. Indicate parents have received required 10 hours of parent preparation training. China requires 12 hours of parent training.  Include a summary of counseling given (discussion of processing, expenses, and difficulties associated with international adoption) and plans for post adoption counseling.

Sample wording: “The (last name) family has or will have received 10 hours (12 hours for China) of Hague compliant parent preparation training prior to their child’s arrival. They have met state regulations regarding parent preparation (if there are state regulations that mandate parent preparation training- cite the regulations and what the specific state requirements are. If no requirements by the state indicate no state requirements). This training includes: child development and the dynamics of inter-country adoption, issues on separation and loss, grief, bonding and attachment, self-esteem, trans-racial families and various age-appropriate issues concerning adoptive families, processing, expenses, difficulties and delays associated with international adoption, as well as the issues involved in parenting a child of another culture and information regarding post placement requirements and process. The family is aware of the medical needs and developmental delays often present in inter-country adoption. [They are prepared to parent a child who is delayed due to institutionalization. The family understands and accepts that a child may have health care/diagnosis according to the normal “standards of care” for an institutionalized child from another country, which may not necessarily be the same level as for children in the U.S]. (For Korea studies only: Do not use the sentences in brackets) More pre-placement counseling will be provided by Holt International (or list name of home study agency) should the need arise. The family will receive a Certificate of Completion when they have completed the 10 hours (12 hours for China) of parent preparation training. This certificate will be maintained in the family’s permanent file at Holt International headquarters. The family will receive post placement counseling from Holt and (list name of home study agency if different than Holt).”

5 RELIGION  PHILIPPINES: Religion must be discussed in detail and under a separate heading as above. Indicate what church family has been attending and for what length of time (Philippines prefers 5+ years of attendance).  INDIA: Does not like proselytizing or evangelizing.  KOREA: Interested in faith of family. Discuss family’s willingness to accept whatever their adopted child’s decision is for religion in the future.  ALL OTHER COUNTRIES: Omit this section from study.  Program social work Directors should be consulted if in doubt about appropriate remarks.  Discuss faith and beliefs, values and religious practice in the home.  If older child, plans to accommodate their religious beliefs or practices.

HOME, COMMUNITY, FINANCES Home  Detailed description of current home (and if they are planning to move, a detailed description of where the child will reside with adoptive parents, if known). Suitability for a child and determination whether space meets state requirements (if any).  Whether home has access to city services (water, sewer, garbage, police and fire protection). If not, describe how services are provided.  Safety concerns, smoke alarms, fire extinguishers.  The condition, cleanliness, housekeeping standards of the home.  If the family has a vacation home or secondary residence but does not reside in the home for extended periods of time and/or it is only utilized during weekends and short holiday breaks, please state so. If the family spends significant time in another residence (lives there during the work week, spends several months there each year), a statement must be made that it meets state requirements.

Community  Discussion of neighborhood and community, access to medical, shopping and educational facilities, racial mix, population of community.  Adoptive family support groups and other adoptive families in the area.  Resources for child with special needs, if applicable.  Must include a statement about the community’s attitude toward and acceptance of persons of different nationalities.

Finances  Include description of income, financial resources, debts and expenses of prospective adoptive parents including statement that social worker has verified information by reviewing supporting documentation (IRS form 1040, US Bank statement #1234, etc.).  Include a statement that employment has been verified for each spouse (if applicable) and the date of the verification letter and who issued it (name of employer, CPA, etc.)  Include value of home and mortgage remaining, value of life insurance and statement whether child can be beneficiary of each plan. Also include value of any other property or assets held by the family.

Sample wording: “According to the 1040 Income Tax Form submitted by Mr. and Mrs. (Name) for 2012, their adjusted gross income was $100,000. Based on the financial statement (provided by Holt or received from name of specific bank, or name of accountant that provided the information) submitted to our agency by Mr. and Mrs. (Name), their monthly expenses are: Mortgage - $1,530; Utilities - $100; Food - $400; Auto Loan - $393, and Child Care - $500. Their net monthly income is $7,500 and their next monthly expenses are $2,923. The (name) family has adequate financial resources to add a child to their family. The (Name)’s home is valued at $220,000 with mortgage remaining of $150,000. The family has savings of $40,000 and IRA/401Ks worth

6 $400,000. (Father’s Name) has a life insurance policy worth $125,000 and (Mother’s Name) has a policy worth $10,000.

GUARDIANSHIP PLAN  Include name and relationship of person(s) the family has named as guardian of their child in the event of their death.  Include age, profession, marital status, health and financial situation of proposed guardians and whether they also have children. Must include a statement from the social worker that the persons named as guardians are suitable to be guardians.  INDIA: Guardians must be a couple (both under age 40). Contact Program Director if unable to identify guardians under age 40.

HEALTH INSURANCE  Paragraph should state the family is covered by medical insurance that will cover pre-existing conditions for each child placed in the home for adoption purposes and that coverage will begin on the day of placement.

REFERENCES  Identify relationship of reference to family, how long they have known family. Summarize key phrases of letters received.  Include number of references received.  If negative reference, discuss fully and show resolution if possible.  CHINA: Include at least three references. References should be obtained from children of the prospective adoptive parents who are over the age of 18. If the prospective adoptive parents have children under the age of 18, one teacher reference is needed (regardless of the number of children in school).

SUMMARY AND RECOMMENDATION  Social Worker must specifically state family is approved to adopt. Do not use the wording “family is open to”.  Include information about the specific profile of child the family is approved to adopt, including:  Nationality - list the name of the country from which the family is adopting.  Age - state age of child at time of child referral and age of child at time of travel, to ensure approved age range covers time of travel (Example: 0 to 3 years at time of referral, 0 to 4 years at time of travel). Whenever possible, put age range in years instead of months.  Gender - list male, female or either gender.  Siblings or multiple children - list if the family is approved to adopt siblings, and if so, the maximum number of children in the sibling group. List the maximum number of children the family is approved to adopt.  Range of special needs - list level of special needs family is approved for (minor, moderate or major) and list as many specific special needs as possible.  If the family is matched with a child outside of the approval parameters in the recommendation section of the home study, the family will have to update their home study and pay a fee to USCIS to ammend their immigration approval.  Include a statement that the home study meets State, USCIS, Hague, and COA standards. Study must indicate that family meets all Hague country program eligibility criteria. The social worker who prepared the home study must sign the study and attest that an interview was conducted in the clients’ home and state that under penalty of perjury all of the information is correct.

Sample wording: “Mr. and Mrs. (name) have met all of the requirements for adoption in the State of (state). This home study report has been prepared in accordance with licensing standards for approved adoption 7 agencies, the State of (state), USCIS, the Hague Convention and the Council on Accreditation. This home study was performed in accordance with 8 CFR 204.311 and any applicable state laws.

Mr. and Mrs.(name) meet or exceed the requirements for adoption as required by (country program) in regard to age, length of marriage, number of children in household, health and physical fitness, criminal clearance, education, employment, income, ability to parent an orphan and are willing and able to comply with post- placement and travel requirements.

I, (social workers name), verify under penalty of perjury under U.S. law that I have personally conducted this home study, including personal interviews, home visits, and all other aspects of the investigation needed to prepare the home study with the professional diligence reasonably necessary to protect the best interest of any child whom the applicant might adopt. The content and factual statements within this home study are true and correct to the best of my knowledge, information, and belief. I have notified the applicants of their duty to disclose and their continued duty to disclose any information or new events per Hague convention regulations (8 CFR 204.309(f)). I certify that this is a true and accurate copy of the home study provided to the prospective adoptive parents.

Mr. and Mrs. (Name) are approved to adopt a female child, age 0-3 years at time of child referral, age 0-4 years at time of travel, from (country program). The family is approved for a child with minor to moderate special needs, including but not limited to a child who is Hepatitis B positive, has thalassemia, or other forms of anemia. The family is also approved to adopt a child with an orthopedic condition affecting the child’s hands or feet, including club feet. It is my pleasure to recommend that (country program) place such a child with the (Name) family of (City, State).”

(Original signature of the home study preparer has to be part of the home study)

Social Worker Name, Degree Title

Supervisory signature if required by State or agency.

Notarization Send draft to Holt for review and approval, send notarized original to Holt upon approval.  If signature page is separate from the body of the home study, family’s name must be listed on the page. o Example: Smith, Signature Page for China Study 9-2013

(Last updated 09/27/13) Common/Adoption Services Department/USCIS/home study guidelines

8