Date of Date Placed Date Exited Race/Ethnicity Gender Primary Special Needs Type of First Name/Last Initial Only Birth/Age in Home Home Language or Concerns Placement Spoken Section II. BACKGROUND SCREENING A. Background checks: Criminal records and Abuse records have been checked for the parent(s), all adults and other persons living in the home, as required. Name Relationship to Identification/ Local NCIC and FCIC Fingerprints Other States Checked Parent listed in Verification of Legal Background Received Section I.A. Parent Status Yes No Y N Y N Y N Y N Date: Date: Yes No Y N Y N Y N Y N Date: Date: Date: Date: Yes No Y N Y N Y N Y N Date: Date: Date: Date: Yes No Y N Y N Y N Y N Date: Date: Date: Date: Additional background checks not listed above [include name of check, (e.g. DJJ, driving record, civil court) name of individuals screened and date of results]: B. Presumption of Detriment Explanation: (If child is not release to the Other Parent, provide explanation/rationale to be presented to court.) Section III. ASSESSMENT and HOME STUDY The purpose of this section is to assess the parent’s ability and willingness to care for child(ren).
First Name/Last Initial Only Date of Birth/Age Date Placed in Home Date Exited Home Race/Ethnicity Gender Primary Language Spoken Special Needs or Concerns Type of Placement Section II. BACKGROUND SCREENING A. Background checks: Criminal records and Abuse records have been checked for the parent(s), all adults and other persons living in the home, as required. Name Relationship to Parent listed in Section I.A. Identification/ Verification of Legal Parent Status Local Background NCIC and FCIC Fingerprints Received Other States Checked Yes No Y N Y N Y N Date: Y N Date: Yes No Y N Date: Y N Date: Y N Date: Y N Date: Yes No Y N Date: Y N Date: Y N Date: Y N Date: Yes No Y N Date: Y N Date: Y N Date: Y N Date: Additional background checks not listed above [include name of check, (e.g. DJJ, driving record, civil court) name of individuals screened and date of results]: B. Presumption of Detriment Explanation: (If child is not release to the Other Parent, provide explanation/rationale to be presented to court.) Section III. ASSESSMENT and HOME STUDY The purpose of this section is to assess the parent’s ability and willingness to care for child(ren).