Home Study Checklist
(Office Use Only)
Temporary Approval Date: ______
End of Temporary Approval: ______
RESOURCE HOME ______
Please complete as items are forwarded to the office (if applicable):
______Home Study I Data Collection (day of initial visit/within 1 week)
______Mandatory Safety Checklist (day of initial visit/within 1 week)
______Egress Map (day of initial visit/within 1 week)
______Disclosure Statement for anyone over the age of 14 years old (day initial visit/within 1 week)
______Childline Clearance Applications for anyone over the age of 14 years old (day of initial visit/within 1 week)
______Criminal Record Check Applications for anyone over the age of 14 years old (day of initial visit/within 1 week)
______FBI Fingerprint Charts (day of initial visit/within 1 week; if applicable)
______Consents to Release Information (day of initial visit/within 1 week)
______Confidentiality Agreement (day of initial visit/within 1 week)
______Child Care/Baby-sitting Information (day of initial visit/within 1 week)
______Temporary Approval Letter (Complete at the time of Home Study I)
______Temporary Approval Certificate (Complete at the time of Home Study I)
______Provider Location Request Form (Complete at the time of Home Study I)
______Application (within 14 days)
______Copy of Marriage License (within 14 days; if applicable)
______Copy of Divorce Decree (within 14 days; if applicable)
______Copy of Birth Certificate (within 14 days)
CC 3:2H
05/07
Page 1 of 3
______ Copy of Death Certificate (within 14 days; if applicable)
______Copy of Driver’s License (within 14 days; if applicable)
______Copy of Non-Driver’s Agreement (within 14 days; if applicable)
______Copy of Vehicle Registration (within 14 days; if applicable)
______Copy of Vehicle Insurance (within 14 days; if applicable)
______Copy of Deed or Lease (within 14 days)
______Copy of Homeowner/Renter’s Insurance (within 14 days)
______Financial Statement (within 14 days)
______Proof of Financial Stability (within 14 days)
______ Credit Report
______ Income Tax Return
______ Bankruptcy Lien
______ Pay Stubs
______ Disability Check
______ Other Income
______Documentation of Protection from Abuse Order (within 14 days)
______Documentation of Family Court Petitions (within 14 days; if applicable)
______Documentation of Drug & Alcohol Related Arrests History (within 14 days; if applicable)
______Documentation of Drug & Alcohol Treatment (within 14 days; if applicable)
______Documentation of Mental/Psychological History (within 14 days; if applicable)
______Documentation of Special Needs Children already present in the home (within 14 days; if applicable)
______Clothing Inventory (within 14 days)
CC 3:2H
Page 2 of 3
______HMO Change Request Form (within 14 days)
______Home Study II Data Collection (Complete at the time of Home Study II)
______Mandatory Safety Checklist Follow-up (Complete at the time of Home Study II)
______Signed Children’s Choice Policies (within 30 days)
______Child Care/Babysitter Form/Clearances/Day Care License (within 30 days)
______Original Child Abuse Clearances (within 60 days)
______Original FBI Fingerprint Charts (within 60 days; if applicable)
______Initial Physical Exam forms for anyone over the age of 18 years. old and Kinship Children w/ TB results (within 60 days)
______Immunization Record (within 60 days)
______Initial Dental Exam for Kinship Children (within 60 days)
______Personal References ____1____2____3 (within 60 days)
______Employment Reference (within 60 days; if applicable)
______Pre-Service I for Caregiver 1 (Date:______)
______Pre-Service II for Caregiver 1 (Date:______)
______Pre-Service I for Caregiver 2 (Date:______)
______Pre-Service II for Caregiver 2 (Date:______)
______Full Approval Letter (60 days from date of approval)
______Full Approval Certificate (60 days from date of approval)
______Provider Location Request Form (60 days from date of approval)
______Resource Parent Registry (60 days from date of approval)