<p> Relative Care Assessment</p><p>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): </p><p>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) </p><p>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. </p><p>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) </p><p>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. </p><p>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)</p><p>G. References: Two references required.</p><p>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.</p><p>J. Summary and Recommendations:</p><p>Complete name(s), signature(s), titles and dates on all required documents and/or forms.</p><p>Case Manager: Date: County DFCS Telephone: </p>