<p> Foster to Adopt Home Development Checklist</p><p> Kinship/Fictive Kinship Foster to Adopt  Unrelated Foster to Adopt</p><p>Family Name: ______Email Address: ______</p><p>Home Address: ______City: ______Zip: ______</p><p>Home Phone: ______Caregiver 1 Cell: ______Caregiver 2 Cell: ______</p><p>Foster to Adopt Orientation Date: ______(Note: 90-day period for Kinship/Fictive Kinship Home Completion / 120-day period for Unrelated Foster to Adopt Home Completion)</p><p>STEP 1: PRE-QUALIFICATION (Please attach all documents) Application – This section must be completed prior to submitting Background Checks. The process must stop if the application is not complete. ___ Prospective Foster to Adoptive Family Inquiry ___ Foster to Adoptive Application - (Completed and signed) ___ Kinship Foster to Adopt (Consent for Release of Information from DFPS Kinship Worker) ___ DFPS Kinship Assessment ___ Foster to Adoptive Family (Consent for Release of Information from previous CPA) If, applicable ___ Foster to Adopt Family Transfer Requirements Acknowledgement / Agreement Form ___ Previous CPA Home Study (if applicable) Background Checks – This section must be completed prior to conducting the initial home pre-verification inspection. ___ Caregiver #1-SHCS Criminal History/ Central Registry Check Consent Form (Class I Abuse Statement) ______Name ___ Caregiver #1-FAST Fingerprint Receipt ___ Caregiver #1-Background Check Results: DFPS ___ Caregiver #1-Background Check Results: DPS ___ Caregiver #1-Bacground Check Results: FBI ___ Caregiver #1-Out-of-State Central Registry Request Form ___ Caregiver #1-Out-of State Central Registry Results</p><p>___ Caregiver #2-SHCS Criminal History/ Central Registry Check Consent Form (Class I Abuse Statement) ______Name ___ Caregiver #2-FAST Fingerprint Receipt ___ Caregiver #2-Background Check Results: DFPS ___ Caregiver #2-Background Check Results: DPS ___ Caregiver #2-Bacground Check Results: FBI ___ Caregiver #2-Out-of-State Central Registry Request Form ___ Caregiver #2-Out-of State Central Registry Results ___ Biological Children residing in the home (who are 14 yrs. of age) – SHCS Criminal History/Central Registry Check Consent Form (Class I Abuse Statement) ______Name ___ FAST Fingerprint Receipt ___ Background Check Results: DFPS ___ Background Check Results: DPS ___ Background Check Results: FBI ___ Out-of-State Central Registry Request Form ___ Out-of State Central Registry Results </p><p>___ Other resident age 14 or older-SHCS Criminal History/Central Registry Check Consent Form (Class I Abuse Statement) ______Name ___ FAST Fingerprint Receipt ___ Background Check Results: DFPS ___ Background Check Results: DPS ___ Background Check Results: FBI ___ Out-of-State Central Registry Request Form ___ Out-of State Central Registry Results Home Pre-verification Inspection – This section must be completed prior to proceeding to STEP 2. If the home possesses any deficiencies the process must stop until all deficiencies are corrected. ___ Initial Environmental Health Checklist (Local Health Department Letter attached) ___ Residential Child-Care Licensing approved variance (if applicable) ___ Initial Fire Safety Prevention Checklist ___ Criminal Background Unit approved risk assessment (if applicable) ___ In-Home Orientation ___ Kinship Assessment Domestic Violence Check ___ Domestic Violence Statement Signed by both Foster to Adopt Parents ___ Domestic Violence Call History from Local Police Department (26 Months for all previous addresses within this time period) </p><p>______/ ______/ ______F.D.S. (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date</p><p>STEP 2: COLLECTION OF PERSONAL DOCUMENTS (Please attach all documents) Personal Identification, Financial, Marital Status and Education Name: ______Caregiver #1-Texas driver’s license ___ Caregiver #1-Birth Certificate ___ Caregiver #1-Social Security Card ___ Caregiver #1-Education (Diploma, Transcripts, or G.E.D) or Foster to Adopt Proficiency Evaluation ___ Caregiver #1-Income verification: must include (60 days of paycheck stubs, 2 months of bank deposit statements, and previous year W-2 statements) ___ Caregiver #1-Divorce Decree or Death Certificate from all previous marriages ___ Caregiver #1-Affidavit signed and notarized </p><p>Name: ______Caregiver #2-Texas driver’s license ___ Caregiver #2-Birth Certificate ___ Caregiver #2-Social Security Card ___ Caregiver #2-Education (Diploma, Transcripts, or G.E.D) or Foster to Adopt Proficiency Evaluation ___ Caregiver #2-Income verification must include: (60 days of paycheck stubs, 2 months of bank deposit statements, and previous year W-2 statements) ___ Caregiver #2-Divorce Decree or Death Certificate from all previous marriages ___ Caregiver #2-Affidavit signed and notarized </p><p>Revised 06/22/2016 ___ Marriage Certificate (current marriage) ___ Birth Cert. for all household members ___ Other-Affidavit signed and notarized (all household members 14yrs & older) ___ Family’s Financial Contingency Plan for the child(ren) being adopted: Life Insurance Policy, Will, Trust-Fund and/or Other Beneficiary Policy (if, applicable) Written References ___ 3 Non-Relative Community (i.e. neighbors, school personnel, clergy, or other unrelated person from the community) ___ 2 Relative (not including biological child) ___ Biological Children age 12 and over not living in the home Health Screening ___ Caregiver #1-Health Statement ___ Caregiver #1-TB test ___ Caregiver #2-Health Statement ___ Caregiver #2-TB test ___ TB tests for all children(including child age 1) and other adult household members Home Description/View ___ External view of home (photos of foster child bedrooms, front, sides, and back yard; including out houses, sheds, other structures and play equipment) ___ Floor plan with all room dimensions and usage (including emergency evacuation routes)</p><p>Home Safety & Equipment ___ Photo of Foster Care OMBUDSMAN Poster: Posted in the Foster Home ___ Photo of First-Aid Kit ___ Photo of Medication Storage (Double Locked System) ___ Photo of Fire Escape Ladder (2 Story Homes or Second Story Apartment Units ONLY) ___ Photo of Fire Extinguisher (5lbs) one for each level (service/tagged is Required) ___ Photo of Fire Evacuation Route Posted in each child’s bedroom ___ Photo of Child Safety Kit install if, fostering infants to 8 years old. (i.e. lower cabinets, electrical covers, stair gate, and bathroom door knobs) (if, applicable) ___ Photo of Home/Apartment Complex Swimming Pools or any standing body of water, lake, pond, etc. (must be secured with a 4 ft. fence around it) including exit-door chime ___ Photo of Water Safety Rescue Equipment (life raft, life vest and pool pole) ___ Photo of Outdoor Hot Tub (must be secured with a 4 ft. fence around it or must be equipped with lid and lock when not in use) ___ Photo of Mattress Covers placed on each child’s mattress (plastic cover is required for a child who wets the bed)</p><p>Home Inspections ___ Local Health Department Service Letter of Denial (must be from the current year of development) ___ Local Health Department Foster Home Inspection (if required by Local Health Department) ___ Final Environmental Health Checklist (not required if, there were no deficiencies found during the initial inspection and maintained compliance during development) ___ Fire Inspection by Local Fire Marshall (not accepting fire inspection performed by an unauthorized Fire Marshall) ___ Gas Pressure Test (if, applicable)</p><p>Fire Arms, Explosive Materials, and Projectiles Safety & Inspections ___ Weapons Safety Documentation Form (completed & signed by all adults residing in the home) ___ Photo of Weapons, Fire Arms, Explosive Materials, and Projectiles Stored and Locked (if, applicable) ___ Photo of Ammunition Stored Separately from Weapon (if, applicable)</p><p>Auto ___ Auto Insurance (all vehicles used to transport children) Pets ___ Pet vaccinations (if, applicable) Frequent Visitors/Temporary Residents ___ Frequent Visitor/Temporary Resident (who are 14 yrs. of age or older)-Criminal History/Central Registry Check Consent Form (Class I Abuse Statement) ___ Background Check Results: DFPS ___ Background Check Results: DPS ___ Background Check Results: FBI (if, lived outside of Texas within the past 5yrs) ___ Frequent Visitor/Temporary Resident Approval Letter and/or ____ Restricted Persons Letter (If, applicable) ______/ ______/ ______F.D.S. (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date</p><p>STEP 3: PRE-SERVICE TRAINING (Please attach all documents) Caregiver #1Training </p><p>Name:______Instructor Led Training ___ Orientation Certificate ___ PRIDE 16hrs (including 8hrs of Emergency Behavior Intervention & Normalcy-“Reasonable and Prudent Parenting Standards”) ___ Trauma Informed Care 6hrs (including Adverse Childhood Trauma and Prevention of Secondary Trauma “Compassion Fatigue”) ___ Integrated Emergency Behavior Intervention & Trauma Informed Care 8hrs (including the use of PAPH) ___ CPR (adult, infant & child) & First-Aid 2hrs ___ Medication Management & Preventing the Spread of Communicable Diseases 1hr (including SHCS Policy & Procedure) ___ Emergency Procedure Planning (including Weather Emergencies DEP & Volatile Persons & Handling Child or Caregiver Emergency Illness Emergencies) 1hr</p><p>Self-Instructed (On-line) Training ___ Psychotropic Medication 2hrs (DFPS website) ___ Trauma Informed Care 2hrs (DFPS website) ___ Medical Consent Training 2.5hrs (DFPS website) ___ Transportation Safety 2hrs (website) ___ Reporting Suspected Abuse or Neglect of a Child 1hr (DFPS website)</p><p>Optional Training (if verified to care for infants to 4 year old toddlers) ___ SIDs 2hrs (DFPS website) ___ Ensuring the Health and Safety of Infants and Toddlers in care 2hrs (DFPS website) ___ Instructor Led Water Safety Training 2hrs (If home or apartment, has a hot tube, pool or standing body of water, lake, pond, etc.) Caregiver #1Training </p><p>Name:______Instructor Led Training ___ Orientation Certificate ___ PRIDE 16hrs (including 8hrs of Emergency Behavior Intervention & Normalcy-“Reasonable and Prudent Parenting Standards”) ___ Trauma Informed Care 6hrs (including Adverse Childhood Trauma and Prevention of Secondary Trauma “Compassion Fatigue”) ___ Integrated Emergency Behavior Intervention & Trauma Informed Care 8hrs (including the use of PAPH) ___ CPR (adult, infant & child) & First-Aid 2hrs ___ Medication Management & Preventing the Spread of Communicable Diseases 1hr (including SHCS Policy & Procedure) ___ Emergency Procedure Planning (including Weather Emergencies DEP & Volatile Persons & Handling Child or Caregiver Emergency Illness Emergencies) 1hr</p><p>Self-Instructed (On-line) Training) ___ Psychotropic Medication 2hrs (DFPS website) ___ Trauma Informed Care 2hrs (DFPS website) ___ Medical Consent Training 2.5hrs (DFPS website) ___ Transportation Safety 2hrs (website) ___ Reporting Suspected Abuse or Neglect of a Child 1hr (DFPS website)</p><p>Revised 06/22/2016 Optional Training (if verified to care for infants to 4 year old toddlers) ___ SIDs 2hrs (DFPS website) ___ Ensuring the Health and Safety of Infants and Toddlers in care 2hrs (DFPS website) ___ Instructor Led Water Safety Training 2hrs (If home or apartment, has a hot tube, pool or standing body of water, lake, pond, etc.) Foster to Adopt Family Training Plan ___ Individual Family Training Plan Additional Training (must be completed within 14 days of verification) ___ New FP 40hrs of Observation Training Occasional Child-Care Providers</p><p>Name:______Attach the Occasional Child-Care Provider Checklist for each caregiver</p><p>Name:______Attach the Occasional Child-Care Provider Checklist for each caregiver</p><p>______/ ______/ ______F.D.S. (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date</p><p>STEP 4: VERIFICATION FOSTER TO ADOPT HOME INTAKE (Please attach all documents) Verification ___ Foster to Adopt Home Study ___ Agency Verification ___ RCCL Form 2953 Foster Home Registration (enter in DFPS Website) ___ RCCL Agency Home License (retrieve from DFPS Website) # ______</p><p>Other Required Documents ___ Home Rules ___ Discipline Plan ___ Discipline Policy-signed ___ Health Care Providers List (Approved STAR Health Providers only) ___ List of local Schools </p><p>Foster to Adopt Home Agreement ___ Statement of Foster to Adopt Parent and CPA Rights and Responsibilities DFPS form 3001 ___ Foster to Adopt Home Agreement ___ Reporting Abuse and Neglect Policy ___ Confidentiality Statement ___ Corporal Punishment policy ___ Appeals Process for Agency Clients ___ Security Policy for the Client Information System & E-mail ___ Foster Care Ombudsman Poster ___ Foster Care Ombudsman Acknowledgement Letter Mis. ___ Foster to Adopt Parent Annual Training Schedule ___ DFPS Medical Transportation Program Letter (signed by both Foster Parents) ___ Direct Deposit (Optional) ___ Emergency/Disaster Policy ___ Foster to Adopt Parent Hand Book Review Confirmation ___ THSTEP Brochure “Acknowledgement of Receipt” ___ DFPS Campaign to Curb Infant Sleeping Deaths (if, applicable) ___ See and Save ___ Watch Kids Around Water ___ Water Safety Policy (if, applicable) ___ Water Safety Plan (if, applicable) ___ Foster to Adopt Home Water Safety Rules (if, applicable)</p><p>Child Initial Services ___ Child’s DFPS Service Plan ___ Physical Exam (must be current within the current calendar year or according to the THSTEP Chart) ___ Hearing Exam for children age 3 and up (must be within 12 months of placement) ___ Vision Exam for children age 3 and up (must be within 12 months of placement) ___ Dental (must be within 12 months of placement) ___ TB Exam (must be within the calendar year) ___ Current Immunization Record</p><p>This section is for Foster to Adopt and Kinship-Foster to Adopt Homes Only</p><p>__ Foster to Adopt Home Compliance Binder</p><p>______/ ______/ ______Program Manager (Sign) Date Program Administrator (Sign) Date Admin (Data Entry) Date</p><p>Revised 06/22/2016</p>