OCFS-5183K (4/2018)

NEW APPLICATION CHANGES (Interim Home Study)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Final Assessment and Determination

Home Finder completes this form for each new application. For changes (interim Home Study), complete sections III-V.

Family Name: / Date: / /
  1. REGULATORY REQUIREMENTS
  • Each foster parent is over the age of 21 18NYCCRR 443.2(c)(1)(i)

No Yes

Explanation:

  • Each member of the household is in good physical and mental health and free from communicable diseases, infection or illness or any physical condition which might affect 18NYCR 443.2(b)(16)(i) / 18NYCRR 421.6(c)

No Yes

Explanation:

  • If both parents work outside the home there is a suitable plan for the care and supervision of the child in foster care at all times.

No Yes

Explanation:

  • The marital status of the applicant(s) does not affect the ability of the parent(s) to provide adequate care

No Yes

Explanation:

  • Three personal references were submitted attesting to each of the applicant’s moral character, mature judgement, ability to manage financial resources and capacity to develop a meaningful relationship with children 18NYCRR (c)(1)(v) / 18NYCRR 421.15(c)(2)

No Yes

Explanation:

  • Applicant understand role of foster parent and has the ability, motivation and psychological readiness

No Yes

Explanation:

  • Other family members understand foster care and the foster child’s role with the family

No Yes

Explanation:

  • History of applicant as foster parent has been verified and is acceptable

No Yes

Explanation:

  • Employment references checked and are acceptable

No Yes

Explanation:

  1. ASSESSMENT OF HOME STUDY COMPONENTS

Partner Relationships

Based on the information provided by the family and your analysis of the applicant, summarize each area below as it impacts the ability to foster and/or adopt.

  • Strengths:
  • Considerations:
  • Supports needed:

Parenting

Bases on the information provided by the family and your analysis of the applicant, summarize each area below as it impacts the ability to foster and/or adopt.

  • Strengths:
  • Considerations:
  • Supports Needed:

Family Relationships

Based on the information provided by the family and your analysis of the applicant, summarize each area below as it impacts the ability to foster and/or adopt.

  • Strengths:
  • Considerations:
  • Supports needed:

Child Interviews

Based on the information provided by the family and your analysis of the applicant, summarize each area below as it impacts the ability to foster and/or adopt.

  • Strengths:
  • Considerations:
  • Supports needed:

Psychosocial

Based on the information provided by the family and your analysis of the applicant, summarize each area below as it impacts the ability to foster and/or adopt.

  • Strengths:
  • Considerations:
  • Supports needed:
  1. Changes (Interim Home Study)

Agency Transfer:

Age of range or gender:

Capacity:

Criminal records result:

Household composition:

Home Address:

Level of care:

Marital status (new application required if adult spouse or foster parent enters home):

Program types:

Reopen a home:

Effective date: / /

  1. Agency Determination

Based on the application, home study, safety review form, medical report, references, and background checks, is this family ready to parent a child in foster care?

Approve application/changes Do not approve application/changes

  1. Family comments:

Enter family comments here:

Date: / /

Applicant:

Applicant:

Home Finder:

Supervisor: