Name of Social Worker Completing: Name of Family: OTHERS RESIDING OR FREQUENTLY IN THE HOME? Yes No DSS CWS 833 attached? APPLICANT DISPOSITION This home is Matched Unmatched Specific Placement Child Resides in home now? The applicant(s) have applied to become a Yes No Resource Family for: Future Placement The applicant applied to accept Foster/Adopt of a Male Female Male or Female Child/children between the ages of and . The applicants are are not Open to placement of a sibling group. If open to a sibling group, how many? If Matched, describe any specific needs this child has that should be considered as part of the permanency assessment: APPLICANT #1 APPLICANT #2 Health Screening Completed: Health Screening Completed: Yes No Yes No Concerns noted: Concerns noted: Parenting Training Completed: BACKGROUND CLEARANCE INFORMATION APPLICANT #1 Department of Date: The Department has reviewed the criminal, child Justice Cleared NOT Cleared welfare and DMV history for this applicant and makes the following determination: Abuse Date: Index Cleared NOT Cleared Approved FBI Records Date: Check Cleared NOT Cleared Not Approved DMV Records Date: Check Cleared NOT Cleared CWS Records Date: Check Cleared NOT Cleared BACKGROUND CLEARANCE INFORMATION continued – APPLICANT #2
Name of Social Worker Completing: Name of Family: OTHERS RESIDING OR FREQUENTLY IN THE HOME? Yes No DSS CWS 833 attached? APPLICANT DISPOSITION This home is Matched Unmatched Specific Placement The applicant(s) have applied to become a Resource Family for: Child Resides in home now? Yes No Future Placement The applicant applied to accept Foster/Adopt of a Male Female Male or Female Child/children between the ages of and . The applicants are are not Open to placement of a sibling group. If open to a sibling group, how many? If Matched, describe any specific needs this child has that should be considered as part of the permanency assessment: APPLICANT #1 APPLICANT #2 Health Screening Completed: Yes No Concerns noted: Health Screening Completed: Yes No Concerns noted: Parenting Training Completed: BACKGROUND CLEARANCE INFORMATION APPLICANT #1 Department of Justice Date: Cleared NOT Cleared The Department has reviewed the criminal, child welfare and DMV history for this applicant and makes the following determination: Approved Not Approved Abuse Index Date: Cleared NOT Cleared FBI Records Check Date: Cleared NOT Cleared DMV Records Check Date: Cleared NOT Cleared CWS Records Check Date: Cleared NOT Cleared BACKGROUND CLEARANCE INFORMATION – continued APPLICANT #2
dss_cws_153-b_rfa_dss_assessment_report.docx