E. Placements Non-Related Children Placed in the Home (by the Department or Agency) If none, mark N/A First Name/Last Initial Date of Date Placed Date Exited Race/Ethnicity Gender Primary Special Needs Type of Only in Home Home Language or Concerns Placement Spoken Section II. BACKGROUND SCREENING A. Background checks: Criminal records and Child Abuse records have been checked for the parent(s), all adults and other persons living in the home, as required. Name Relationship to Identification/ 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: 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.)
E. Placements Non-Related Children Placed in the Home (by the Department or Agency) If none, mark N/A First Name/Last Initial Only Date of 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 Child 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 Background NCIC and FCIC Fingerprints Received Other States Checked 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: 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.)
OPHAForm102513.docx