CHECKLIST FOR FAMILIES Resource Family
County Referred
Private Home Study
Name ______
Dates received or completed:
_____Registration information form including 10 years of addresses for each parent
_____Client Grievance Policy
_____Family Training plan and TOLs
______Family Profile Authorization Agreement
______Autobiography for each partner
______Birth Certificate for each partner
______Medical report for each partner
______Medical Self Questionnaire Form for each partner
_____Medical reports –Children
_____Marriage certificate copy (if applicable)
_____Financial statement for household
_____ Copy of tax return for last year
______Copy of pay stubs
______Letter from employer
______List of jobs for past ten (10) years or copy of resume
______Copy of Social Security earnings and/or benefits letter
______Divorce decree(s) or death certificate(s) on previous marriages
______Custody Order for children (in cases of divorce)
______PA Child Abuse clearance (Form CY-113)
______Child Abuse reports for other states where you resided (last five years)
______PA State Police Criminal history clearance (Form SP4-164)
______CogentFBI clearances with DPW letter
______Act 160 Form for each partner
_____Deed to Home or proof of rental
_____Homeowners or Renter’s insurance
_____Copy of any documents related toBankruptcy or liens
_____Guardianship Form
______List of references (4)List names below
______
For Each Person18 and over in home at least 30 days/year:
______PA State Police Clearance
______PA Child Abuse Clearance
______Act 160 questionnaire
______COGENT fingerprint record
Dates of Coordinator checks:
______Call to local Bankruptcy Court—Results ______
______Call to local police (list):______Results: ______
______Call regarding PFA for or against parents –Results:______
______HIPAA release form signed at time of review
______PAE Registration completed
______Letter notifying family of approval status mailed.
___
------For Resource Families ------
_____Copy of Driver's license
_____Proof of Insurance and Registration of all cars
_____Proof of CPR/First Aid course
_____Signed copy of program discipline policy
_____Signed copy of program grievance policy
_____Signed copy of proof of attendance at foster care orientation
_____Disaster Plan
_____Proof of CPSL training for each parent
_____Proof of Reasonable and Prudent Parent training for each parent