iowa department of human servicesdhs.iowa.gov/sites/default/files/12-b-a50.pdf · strength/needs...

1305 E. Walnut Street, Des Moines, IA 50319-0114

Iowa Department of Human Services

Terry E. Branstad Kim Reynolds Charles M. Palmer Governor Lt. Governor Director

February 10, 2017

GENERAL LETTER NO. 12-B-AP-50

ISSUED BY: Bureau of Child Welfare and Community Services Division of Adult, Children and Family Services

SUBJECT: Employees’ Manual, Title 12, Chapter B, Appendix, FOSTER FAMILY HOME LICENSING APPENDIX, Contents (pages 1 and 2), revised; pages 7, 14, 14a, 14b, 23 through 29, 40b, and 43 through 48, revised; page 14c, new; and the following forms:

470-4657 Firearms Safety Plan, revised 470-2470 Foster Home Insurance Fund Claim, new 470-5438 Progress Notes, new 470-0643 Request for Child and Dependent Adult Abuse Information,

revised 470-5436 Resource Parent Home Study, new

Summary

Chapter 12-B-Appendix is revised to:

♦ Update form 470-4657, Firearms Safety Plan.

♦ Add form 470-2470, Foster Home Insurance Fund Claim. Foster parents use this form to submit a foster home insurance claim.

♦ Add form 470-5438, Progress Notes. This form will be used instead of form 470-4512, Unannounced Visit Report, for both announced and unannounced vitis.

♦ Revise and rename form 470-0643 from Request for Child Abuse Information to Request for Child and Dependent Adult Abuse Information.

♦ Add form 470-5436, Resource Parent Home Study. This form replaces RC-0025, Home Study Summary and Recommendation Outline.

♦ Remove the instructions and the following obsolete forms:

• RC-0025, Home Study Summary and Recommendation Outline • 470-4512, Unannounced Visit Report

Effective Date

Upon receipt.

- 2 -

Material Superseded

This material replaces the following pages from Employees’ Manual, Title 12, Chapter B, Appendix:

Page Date

Contents (pages 1 and 2) July 29, 2016 470-4657 2/11 7 February 18, 2011 14, 14a, 14b July 29, 2016 RC-0025 9/09 23-29 July 24, 2015 40b November 16, 2012 470-0643 9/05 43-47 August 6, 2010 48 February 8, 2013 470-4512 2/13

Additional Information

Refer questions about this general letter to your area social work administrator.

Title 12: Licensing and Approval Standards TABLE OF CONTENTS Chapter B: Foster Family Home Licensing Appendix Revised February 10, 2017 Page 1

Page

Iowa Department of Human Services Employees’ Manual

Certificate of Completion, Form 470-3378 ............................................................. 1

Certificate of License, Form 470-0727 .................................................................. 2

DHS Criminal History Record Check, Forms 595-1396 or 595-1396(S) ...................... 3

Eco-Map, Form 470-4086 or 470-4086(S) ............................................................. 4

Family Map, Form 470-4087 or 470-4087(S) ......................................................... 5

Final Strengths/Needs Worksheet, Form 470-4022 or 470-4022(S) .......................... 6

Firearms Safety Plan, Form 470-4657 .................................................................. 7

Floor Plan, Form 470-5097 .................................................................................. 8

Foster Care Private Water Supply Survey, Form 470-0693 ...................................... 8b

Foster Family Home License Application, Form 470-0689 or 470-0689(S) .................. 9

Foster Family Record Check Letter, Form 470-2369 ............................................... 11

Foster Family Survey Report, Form 470-0695 ....................................................... 12

Foster Home Insurance Fund Claim, Form 470-2470 ............................................. 14

Foster Home Licensing Corrective Action Plan, Form 470-5404............................... 14a

Foster Parent Post-Adjudication Hearing Report, Form 470-4614 ............................ 14c

Foster Parent Training Application, Form 470-2541 or 470-2541(S) ......................... 15

Foster Parent Training History, Form 470-2080 ..................................................... 17

Foster Parent Training Plan, Form 470-3341 ......................................................... 18

Foster Parent Training Report, Form 470-2540 or 470-2540(S) ............................... 19

Foster/Adoptive Parent Preparation Training Certificate of Completion, Form 470-2066 ........................................................................................... 20

Health Report for Foster and Adoptive Parents, Form 470-0720 .............................. 21

HIV General Agreement, Form 470-3226 or 470-3226(S) ....................................... 22

Lead Paint Assessment, Form 470-4819 .............................................................. 23

License Capacity Variance Request, Form 470-3342 .............................................. 24

Notice of Action: Foster Family Home, Form 470-0709 or 470-0709(S) ................... 25

Partnership Development Plan, Form 470-4020 .................................................... 27

Professional Development Plan, Form 470-4023 .................................................... 28

Progress Notes, Form 470-5438 ......................................................................... 29

Title 12: Licensing and Approval Standards TABLE OF CONTENTS Chapter B: Foster Family Home Licensing Appendix Revised February 10, 2017 Page 2

Page


Provisions for Alternate Water Supply, Form 470-0699 .......................................... 30

PS-MAPP Family Profile, Form 470-4019 or 470-4019(S) ........................................ 31

PS-MAPP Family Profile Summary, Form 470-4029 ................................................ 33

Receipt of HIV-Related Information, Form 470-3227 ............................................. 34

Recommendation for Denial of a Foster Family License, Form 470-0704 ................... 35

Recommendation for Provisional License, Form 470-0698 ...................................... 36

Recommendation for Suspension of a License, Form 470-0710 ............................... 37

Record Check Decision, Form 470-2386 or 470-2386(S) ........................................ 38

Record Check Evaluation, Form 470-2310 or 470-2310(S) ..................................... 39

Request for a One Year Foster Family License, Form 470-5124 ............................... 40

Request for Child and Dependent Adult Abuse Information, Form 470-0643............. 40b

Request for Revocation of Foster Family License, Form 470-0705 ............................ 41

Request for Waiver of PS-MAPP or Licensing Standards, Form 470-4873 .................. 42

Resource Parent Home Study, Form 470-5436 ...................................................... 43

Strengths/Needs Worksheet – After Meetings 1 and 2, Form 470-4021 or 470-4021(S) ............................................................................................... 44

Strength/Needs Worksheet – After Meetings 3 and 4, Form 470-4089 or 470-4089(S) ............................................................................................... 45

Strength/Needs Worksheet – After Meeting 5, Form 470-4090 or 470-4090(S) ......... 46

Strength/Needs Worksheet – After Meetings 6 and 7, Form 470-4091 or 470-4091(S) ............................................................................................... 47

Strengths/Needs Worksheet for Fertility Issues, Form 470-4024 or 470-4024(S) ....... 48

Medication Management, Comm. 315 or Comm. 315(S) ......................................... 49

Foster Parent Handbook, Comm. 33 or Comm. 33(S) ............................................ 50

470-4657 (Rev. 2/17)


Firearms Safety Plan

Professional permit Peace officer permit Nonprofessional permit Reserve peace officer permit No permit

Permit number ___________________________

Attach copy of current, valid firearms permit. (Please note that some peace officers may not be required to have a permit.)

I, ____________________________________________, certify that I have a current, valid Iowa permit to carry firearms. I will provide the Department of Human Services a written plan to keep weapons secure from children in the guardianship and custody of the Department of Human Services.

Name Date

SAFETY PLAN: Describe how children will not have access to the firearms, to your gun lock, and the key to the gun safe. Describe how you will monitor.

Title 12: Licensing and Approval Standards Page 7


Chapter B: Foster Family Home Licensing Appendix Firearms Safety Plan Revised February 10, 2017 470-4657

Firearms Safety Plan, Form 470-4657

Purpose Form 470-4657, Firearms Safety Plan, is a written safety plan to keep firearms secure from children in the foster home who are in the guardianship or custody of the Department.

Source The foster parent can print this form from the on-line policy manual or the contractor home study worker can provide a copy of the form to the foster parent to complete.

Completion The foster parent who has a permit to carry a firearm or does not have a permit but has firearms:

♦ Completes the form, and ♦ Attaches a copy of their current, valid permit to carry

firearms.

The safety plan describes how children will not have access to firearms, the gun lock, and key to the gun safe. It will describe how the foster parent will monitor.

Distribution The foster parent completes the Firearms Safety Plan and gives it to the home study worker. The recruitment and retention contractor includes the form in the home study provided to the Department.

Data The form documents the type of permit or lack of permit, the permit number, and the safety plan.

http://dhs.iowa.gov/sites/default/files/470-4657.pdf



Chapter B: Foster Family Home Licensing Appendix Foster Home Insurance Fund Claim Revised February 10, 2017 470-2470

Foster Home Insurance Fund Claim, Form 470-2470

Purpose The Foster Home Insurance Fund Claim is used by foster parents to submit a claim to the foster home insurance contractor for damages caused by a foster child.

Source Complete this form using the sample in the on-line manual or ask the Department licensing worker to email a copy of the template that is available in the public state-approved forms folder on Outlook.

Completion The foster parent completes the Foster Home Insurance Fund Claim by describing the loss and damages and submitting the form to the foster home insurance contractor along with a copy of their foster home license.

Distribution The original is kept in the foster home insurance contractor’s case file.

Data Complete all items on the form.


470-2470 (Rev. 11/16)


Foster Home Insurance Fund Claim

Foster Family Name

Foster Child Name

Foster Home Address

Home Phone Number Cell Phone Number

Work Phone Number Email Address

Date of Loss

Description of loss/damages:

Attach a copy of your foster home license to this form.

Title 12: Licensing and Approval Standards Page 14a


Chapter B: Foster Family Home Licensing Appendix Foster Home Licensing… Revised February 10, 2017 470-5404

Foster Home Licensing Corrective Action Plan, Form 470-5404

Purpose The Foster Home Licensing Corrective Action Plan is a form used to document the corrective action plan. Its purpose is to assist the foster family in meeting all licensing standards and to prevent the denial, revocation or suspension of their foster family home license.

Source Complete this form on line using the template available in the public state-approved forms folder on Outlook. This form may also be printed from the sample in the manual.

Completion The Foster Home Licensing Corrective Action Plan is completed when:

♦ The Department licensing worker engages the foster family and other team members in developing this action plan,

♦ The foster family does not meet licensing standards, or

♦ Has issues that may negatively impact foster children.

Take into consideration the circumstances, the foster family’s history, their willingness to take responsibility and make adjustments, and other relevant factors when deciding whether or not to complete a corrective action plan (CAP).

The foster family may document their responses to the corrective action plan on the form.

Distribution Keep the original. File the signed form in the licensing case file. Provide a copy of the signed form to:

♦ The foster parents, ♦ The recruitment and retention provider and, ♦ To other team members, as needed.


Title 12: Licensing and Approval Standards Page 14b


Chapter B: Foster Family Home Licensing Appendix Foster Home Licensing… Revised February 10, 2017 470-5404

Data Complete the:

♦ Names of the licensees. ♦ Date. ♦ Address and phone number of the home. ♦ License renewal month. ♦ Licensed capacity of the foster family home. ♦ Start and end date of the corrective action plan. ♦ Concerns that led to the corrective action plan. ♦ Legal references. ♦ Conditions that need to change. ♦ Action steps.

Title 12: Licensing and Approval Standards Page 14c


Chapter B: Foster Family Home Licensing Appendix Foster Parent Post-Adjudication… February 10, 2017 470-4614

Foster Parent Post-Adjudication Hearing Report, Form 470-4614

Purpose The Foster Parent Post-Adjudication Hearing Report is a form that the foster family can elect to fill out to provide information to the court about the welfare of the foster child in their care. Foster parents have a right to attend court hearings but are not required to attend.

Source Foster parents may print the form from the sample in the manual. The recruitment and retention contractor will give the form to a foster parent who does not have Internet access to print the form.

Completion This form is an elective for the foster parents and is not mandated to be completed. A foster parent may complete this form by hand or type in the responses and may add attached pages for any narrative that does not fit on the form.

Distribution The foster parent may submit the report to the foster child’s attorney, the child’s Department social work case manager, the juvenile court judge, and other attorneys who are a part of the case, as all parties are entitled to a copy. Keep a copy in the child’s case file.

Data If the foster parents attend the court hearing, they may be called to testify about the information in this report.





Chapter B: Foster Family Home Licensing Appendix Lead Paint Assessment Revised February 10, 2017 470-4819

Lead Paint Assessment, Form 470-4819

Purpose Form 470-4819, Lead Paint Assessment, serves to document that the foster family completed a visual assessment for lead hazards when their residence was built before 1960.

Source The foster parent can print this form from the manual or the recruitment and retention contractor worker can provide a copy of the form to the foster parent to complete.

Completion A foster parent whose residence was completed before 1960 shall complete the form:

♦ During the initial home study. ♦ When the family has moved to a new home. ♦ Annually.

Distribution The foster parent gives the completed form to the recruitment and retention contractor home study worker. The contractor includes the form in the home study packet provided to the Department.




Chapter B: Foster Family Home Licensing Appendix License Capacity Variance Request Revised February 10, 2017 470-3342

License Capacity Variance Request, Form 470-3342

Purpose Form 470-3342 is used to compile the information needed to request a variance to exceed licensed capacity or a child-specific variance from the service area manager or designee.

Source Complete this form on line using the template available in the public state-approved forms folder on Outlook.

Completion The Department licensing worker prepares this form whenever a respite placement is planned which would exceed the licensing capacity. The recruitment and retention contractor worker prepares the form when a match occurs and the placement exceeds licensed capacity.

The recruitment and retention contractor and the placement worker are responsible for ensuring that the additional children placed receive the same level of care and safety as the other children in care.

The service area manager or designee must approve all variance requests.

Distribution Submit the form to the service area manager or designee for approval. The service area manager or designee sends the completed original to the worker responsible for the DHS licensing file.

File one copy in the child’s file. Send a copy to the foster parents for their personal records. Send a copy to the recruitment and retention contractor for their file.

Data Enter the identifying information for the family.

Check the kind of variance being requested.

Explain why the variance is needed and how the family is qualified to provide care for more children.

If the variance is for specific children, enter identifying information for them.




Chapter B: Foster Family Home Licensing Appendix Notice of Action: Foster Family… Revised February 10, 2017 470-0709 or 470-0709(S)

Notice of Action: Foster Family Home, Form 470-0709 or 470-0709(S)

Purpose Form 470-0709 or 470-0709(S) is used to notify the applicant for a foster family home license of licensing decisions.

Source Complete the English version of the form on line using the template in the public state-approved forms folder on Outlook.

Print supplies of the Spanish version of the form from the sample in the manual.

Completion The service area manager or designee completes the form when the manager or designee makes a foster family home licensing decision, including:

♦ Issuance of a full license on application, reapplication, or completion of a corrective action plan under a provisional license.

♦ Issuance of a provisional license on application or reapplication.

♦ Denial of a license on application, reapplication, or expiration of a provisional license.

NOTE: If the applicant fails to return the application for renewal, then the license is not renewed. The notice is effective the last day of the licensing year.

The service area manager or designee reviews and signs the form.

Distribution Make three copies of the completed form. Send the original to the applicant. NOTE: Send all denial notices to the applicant by restricted certified mail so that the date of receipt can be recorded for appeal purposes.


http://dhs.iowa.gov/sites/default/files/470-0709S.pdf



Chapter B: Foster Family Home Licensing Appendix Notice of Action: Foster Family… Revised February 10, 2017 470-0709 or 470-0709(S)

The service area manager may send a letter with this notice of action, especially in the case of adverse actions. Any information contained in the letter shall agree with the information and appeal rights contained on this form.

File a copy in the Department licensing file. Send a copy to the recruitment and retention contractor.

The contractor will initiate payment of the training stipend if the license is approved.

Data Indicate if a new license or renewed license is being issued.

Check the applicable choice and fill in the dates and license capacity if requested.

If a full or provisional license is being issued, indicate the effective period of the license and the capacity of the home. If any other limitations are being placed on the home, type the limitation in the space provided.

If the application is being denied:

♦ Indicate all specific sections of Iowa Code Chapter 237 and of 441 Iowa Administrative Code Chapters 112 and 113 being used as reasons for the denial. Include the number and a direct quote of the section.

♦ Explain the specific facts that support the legal basis for the negative action. Use an additional page if necessary.



Chapter B: Foster Family Home Licensing Appendix Partnership Development Plan Revised February 10, 2017 470-4020

Partnership Development Plan, Form 470-4020

Purpose The purpose of form 470-4020, Partnership Development Plan, is to help families turn their needs into strengths and enhance their parenting skills.

Supply Print supplies of this form from the sample in the manual.

Completion The contractor home study worker completes this form during the family consultations. This process may be completed as often as necessary. Issues identified must be addressed by the tenth training session.

Distribution Keep the original of the form in the home study file and make a copy for the family.

The home study worker shares this information with the PS-MAPP training leaders as feedback indicating what subjects need to be addressed during the training. If PS-MAPP training is waived, this form can be completed and shared with the Department when the initial licensing packet is submitted.

Data The form identifies the family’s need, indicates what action plan will be implemented to address the need, and analyzes the potential outcomes of this process.




Chapter B: Foster Family Home Licensing Appendix Professional Development Plan Revised February 10, 2017 470-4023

Professional Development Plan, Form 470-4023

Purpose The purpose of form 470-4023, Professional Development Plan, is to identify training needs for foster families during the first six months after they receive their license to enhance their parenting skills.

Supply Print supplies of the form as needed from the sample in the manual.

Completion The home study worker completes this form in consultation with the family so they can work out a training plan for the family.

Distribution The home study worker maintains the original of the form in the home study file and makes a copy for the family.

Data The form identifies:

♦ In-service training needs for the family, ♦ Needs for development of other family members, and ♦ The plan the family agrees to carry out to meet those

needs.


470-5438 (Rev. 2/17) Page 1


Progress Notes

Announced Visit Unannounced Visit

Date:

Who was Present

List the retention and recruitment worker, DHS caseworker or licensing worker, and all household members present during the visit.

Location of Contact

Purpose of Contact

Licensing visit Support visit Visit related to a concern Other purpose:

Progress Note Narrative

Include a brief synopsis of what took place during the meeting.

Discussion with the Foster Parents Regarding Each Foster Child in the Home

Document your discussion with the foster parents below. Cover the four primary domains for each child.

Name of Child Health Education Behavior Socialization Name of Child

470-5438 (Rev. 2/17) Page 2

Health Education Behavior Socialization Name of Child Health Education Behavior Socialization

Medications

Describe below your conversation with the foster parents about:

• Any side effects the child may be having; • The child’s current medications, including any psychotropic medication; and • Review the current therapeutic plan.

Describe below the support and coaching you provided to the foster parents on concerns discussed.

Describe the foster child’s perception of the home.

Discuss license capacity.

Training

Foster home licensing year:

List the trainings by each foster parent’s name below. Include the training name, training provider, training date, and the number of training hours completed in the foster parent’s current license year.

470-5438 (Rev. 2/17) Page 3

Name Training Name Training Provider Training Date

Training Hours Completed

Document the conversation on the topics of trainings and number of hours that need to be completed before the foster home license renewal.

Include DHS or retention and recruitment worker’s recommendations for trainings based on an assessment of foster parent’s skills, needs, and challenges for specific children in the home.

Concerns to be Addressed and the Safety Assessment

Describe the physical condition of the home. (You may want to take pictures.)

Describe the discipline or behavior management techniques being used by the foster parent.

Describe any other issues noted during the visit.

Next Steps

Who will do what and by when.

The next steps should consider the severity of concerns assessed during the visit and should note if the concerns rise to the level of DHS or the retention and recruitment to complete a joint visit.



Chapter B: Foster Family Home Licensing Appendix Progress Notes Revised February 10, 2017 470-5438

Progress Notes, Form 470-5438

Purpose Progress Notes is used to document foster home visits in the narrative of what took place and address:

♦ People present,

♦ Location of contact,

♦ Purpose of contact,

♦ Home environment,

♦ Foster child’s perception of the home,

♦ Each foster child’s health, education, behavior, and socialization,

♦ In-service training progress and list training completed

♦ License capacity discussion,

♦ The conversation about the child’s current medications and review the current therapeutic plan,

♦ Other issues noted, and

♦ The next steps (who will do what by when).

Source Complete this form on line using the template available in the public state-approved forms folder on Outlook. In the future this template will be moved to SharePoint.

Completion The recruitment and retention licensing worker completes the Progress Notes after consulting with the Department licensing and placement worker.

Distribution Keep the original in the child’s case file. Provide a copy to the resource parents.

Data Complete a new Progress Notes form for each visit and annually for the unannounced visit.



Title 12: Licensing and Approval Standards Page 40b


Chapter B: Foster Family Home Licensing Appendix Request for Child and Dependent… Revised February 10, 2017 470-0643

Request for Child and Dependent Adult Abuse Information, Form 470-0643

Purpose Form 470-0643 is used to document a request for information from the Central Abuse Registry to determine whether there is a record of a founded abuse report on a person in the foster family household.

Source Department staff can complete this form on line using the template available in the public state-approved forms folder on Outlook.

Completion Recruitment and retention contractor staff complete the form when a family is being evaluated on a new or renewal application for a foster family home license. Complete a separate form for each person.

For guidelines on checking abuse records for license renewals, refer to 12-B, RENEWAL OF LICENSE: Records Check for Renewal. Make the check through the SING system.

Distribution If the name is found on the Registry as the person responsible for a registered incident, send a copy of the form to the Central Registry office to request a copy of the report.

File the form in the in the home study file with the SING response attached.

Data Complete Sections I, II, and III, requesting any founded or undetermined child abuse reports indicating the foster parent or other household member as the person responsible for abuse, for the purpose of a registry check for foster family home licensing.


http://dhs.iowa.gov/sites/default/files/12-B.pdf

470-0643 (Rev. 2/16) Copy 1: Central Registry or Designee Copy 2: County Office


Request for Child and Dependent Adult Abuse Information Persons or agencies with authorized access to child or dependent adult abuse information must use this form to request information about a child or dependent adult abuse report. Complete a separate form for each family or individual and email to [email protected], or fax to (515) 564-4112, or mail to the Iowa Department of Human Services, Central Abuse Registry, P.O. Box 4826, Des Moines, IA 50305.

Please specify your type of request by checking the appropriate box below: Child abuse request Dependent adult abuse request Both

Please specify your preferred method of response by checking a box and completing the information in Section 1. Address Fax Email

Section 1: To be completed by the person or agency requesting the information. Requester: Last

First

Agency Name

Telephone Number ( )

Address

Fax Number ( )

City

State

Zip Code

Email

Relationship to the persons listed in Section 2 or 3: Purpose for request: State the Iowa Code section that allows access to the child or dependent adult abuse information requested:

I have read and understand the legal provisions for handling child or dependent adult abuse information which is printed on the second page of this form. I understand that this request will not be approved unless I have authorized access. Signature of Requester

Date

Complete Section 2 if the purpose of this record check is employment, licensing or registration, or payment approval.

Section 2: List the name and address of the person whose record is being checked. Last

First

Middle

Birth Date

Social Security Number

Address

City

County

State

Zip Code

List maiden name, any previous married names, and any alias: Complete Section 3 if the request is for a copy of the written summary of the abuse investigation or assessment.

Section 3: List the name of the persons for whom you are requesting information. Attach pages for additional family members.

Last First Middle County Birth Date Social Security # Address

City

State

Zip Code

List maiden name, any previous married names, and any alias:

Section 4: Registry or designee decision.

This request for information is approved. This request for information is denied because:

Signature of Registry or Designee

Date

mailto:[email protected]

470-0643 (Rev. 2/16) Copy 1: Central Registry or Designee Copy 2: County Office

LEGAL PROVISIONS FOR HANDLING CHILD AND DEPENDENT ADULT ABUSE INFORMATION

Redissemination of Child and Dependent Adult Abuse Information (Iowa Code sections 235A.17 and 235B.8)

A person, agency, or other recipient of child or dependent adult abuse information shall not redisseminate (release) this information, except that redissemination is permitted when ALL of the following conditions apply:

♦ The redissemination is for official purposes in connection with prescribed duties or, in the case of a health practitioner, pursuant to professional responsibilities.

♦ The person to whom such information would be redisseminated would have independent access to the same information under Iowa Code sections 235A.15 or 235B.6.

♦ A written record is made of the redissemination, including the name of the recipient and the date and purpose of the redissemination.

♦ The written record is forwarded to the Central Abuse Registry within 30 days of the redissemination.

Criminal Penalties (Iowa Code sections 235A.21 and 235B.12)

A person is guilty of a criminal offense when the person:

♦ Willfully requests, obtains, or seeks to obtain child or dependent adult abuse information under false pretenses, or

♦ Willfully communicates or seeks to communicate child or dependent adult abuse information to any agency or person except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6, and 235B.8, or

♦ Is connected with any research authorized pursuant to Iowa Code sections 235A.15 and 235B.6 and willfully falsifies child or dependent adult abuse information or any records relating to child or dependent adult abuse.

Upon conviction for each offense, the person is guilty of a serious misdemeanor punishable by a fine or imprisonment.

Any person who knowingly, but without criminal purposes, communicates or seeks to communicate child or dependent adult abuse information except in accordance with Iowa Code sections 235A.15, 235A.17, 235B.6, and 235B.8 is guilty of a simple misdemeanor punishable, upon conviction for each offense, by a fine or imprisonment.

Any reasonable grounds for belief that a person has violated any provision of Iowa Code Chapters 235A or 235B shall be grounds for the immediate withdrawal of any authorized access that person might otherwise have to child or dependent adult abuse information.

REQUESTS FOR CORRECTION OR EXPUNGEMENT OF A CHILD OR DEPENDENT ADULT ABUSE REPORT

To request an administrative appeal hearing of a child or dependent adult abuse report, please submit a request in writing to: Department of Human Services, Appeals Section, 5th Fl, 1305 E Walnut St, Des Moines, Iowa 50319-0114. You will be notified in writing acknowledging receipt of your request; time, date, and place of your hearing; and any decisions regarding your request. If you disagree with this decision, the written notice will explain how you may request an administrative hearing about the report and its conclusions per Iowa Code sections 235A.19 or 235B.10.

470-5436 (11/16) Page 1 of 7


Resource Parent Home Study

Date

Foster Parent Home Study Adoptive Parent Home Study Foster/Adoptive Parent Home Study Initial Renewal Initial Renewal Initial Renewal

General Home Study Information

Licensing Agency Licensing Worker

Recommended Approval:

Foster home license Adoption approval Foster home license and adoption approval

Recommended Foster Home License Capacity:

Parents’ Information

Please include all adults that live in the home. Name Name

Race Race

SSN (last four numbers) DOB SSN (last four numbers) DOB

Work Phone Education Work Phone Education

Occupation Annual Net Income Occupation Annual Net Income

Cell Phone Email Cell Phone Email

Marital Status Cohabitating

Religion Marital Status Cohabitating

Religion

Child care provider: Yes No Child care provider: Yes No Type Type

Other child/adult services in the home: Yes No Other child/adult services in the home: Yes No Type Type

Address City Zip

Home Phone School District

470-5436 (11/16) Page 2 of 7

Children’s Information

Please include all children that live in the home. Include relationship: Bio (B), Adoptive (A), or Foster (F), Relative (R), Suitable Other (S), Other (O – please describe) Name DOB M F Relationship Race

Name DOB M F Relationship Race









Discussion with Resource Parents

The purpose of the home study discussion is to better understand how foster and adoptive families will be impacted when a child is placed with them.

Initial Home Study

Please include with this home study a picture of the family. If this is an initial foster or adoptive home study, address in discussion with the foster or adoptive parents:

Becoming a Foster or Adoptive Family

Background. For each applicant:

Name.

Describe:

• Where the applicant grew up.

• The applicant’s relationship with and location of their parents and siblings.

• The applicant’s past and present relationship, location, and amount of contact with their parents and with their siblings.

• The applicant’s grief and loss issues (infertility, loss of parent, child, spouse, etc.) and an example of how each applicant coped with their emotions around grief and loss.

• Any disconnected relationships in their family and why.

• Significant events that have occurred in their family and how these events impacted their family.

470-5436 (11/16) Page 3 of 7

• Positive events including special family activities, hobbies, etc.

• Any history of abuse of the applicant or a family member.

• How they reacted to the abuse.

• How the applicant deals with rejection, criticism, and adversity.

• If the applicant is open to receiving feedback and seeking help and support when the applicant or a foster or adoptive child needs it.

• The applicant’s motivation for becoming a foster or adoptive family. (Mutual interest; why they came to apply) How does the applicant see their adaptation to the change in their family when a child is placed with them.

• What the applicant will enjoy about fostering or adoption, and their understanding of being a foster or adoptive family.

• The applicant’s strengths, weaknesses, and needed supports.

• The applicant’s current occupation, work schedule as to their flexibility for handling a crisis or emergency when there is a foster or adoptive child placed in their home.

• What is the applicant’s child care plan if a child was placed with them.

• The applicant’s highest level of education.

• The sufficiency of the applicant’s income to meet the child’s basic needs.

• Previous applications for foster care or adoption, if any, and the outcome.

• If applicable, the applicant’s previously unfavorable home study or relicensing, denial or revocation of a foster home licensing or adoption approval.

Parenting. Describe how the applicants respond to the following:

How each applicant supervises their children.

Each applicant’s training experience, experience with working with children and children with special needs, or other professional and occupational skills that would assist them in parenting a foster or adoptive child.

Their children’s ages, behaviors, and needs the applicants feel confident or not confident they can or cannot handle.

Their community and school resources that are available for the foster or adoptive child’s educational needs.

What each applicant’s expectations are for a foster or adoptive child academically.

Each applicant’s discipline methods, behavior strategies used, family or house rules.

Each applicant’s perspective on the training and discipline requirements for foster parents in relation to foster children and, if it is different from their own parenting techniques, how will they approach that when fostering.

How each applicant was parented growing up, and if they would parent the same or differently.

Each applicant’s support system for parenting.

Each applicant’s physical or mental health problems, issues, and history of mental health needs that would impact their ability to parent.

Each applicant’s understanding of confidentiality.

470-5436 (11/16) Page 4 of 7

Children in the home. If applicable, include the applicant’s children’s names, ages, and grade level in school.

If open enrollment is available.

Describe how the applicants respond to the following:

• Each child’s personality.

• Describe:

Their children’s attitude toward a foster or adoptive child living in their home, and how the applicants think their children will adjust to this change.

What a typical day is for their children.

The activities their children enjoy doing as a family or on their own.

What are the rules in the home.

What their children will enjoy about having a foster or adoptive child in their home.

What their children will be worried about having a foster or adoptive child in their home.

Each child’s physical or mental health problems and issues that could impact foster or adoptive children.

Other adults in the home. Relationship to the applicants.

Nature and history of presence in the home.

Current circumstances (occupation, relationships, etc.).

Personal background information.

Attitude and experience with special needs foster care or adoption.

Anticipated interactions with foster children.

Physical or mental health problems or issues that could impact foster or adoptive children.

Relationships.

If the applicants are married or cohabitating with a partner:

• Describe:

Their relationship and how long have they been together. Each person’s role in the relationship. How they make decisions and how they handle disagreements. The couple’s current support system.

• Verification of any marriages and divorces. Note the dates of the marriage and divorce decrees.

If the applicant is single, describe:

• Any significant or current relationships.

• How the applicant thinks a special needs foster or adoptive child will impact the applicant and their current or future relationship.

• The applicant’s current support systems.

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Other relationships. Describe:

What is the parenting or caretaker role of the other adults living in the home.

What role the applicants’ parents or extended family will play in regards to foster or adoptive children.

Their parents or extended family support of the applicants’ being a foster or adoptive parent.

The potential safety and risk concerns with extended family support.

The applicants’ ability to work with birth families and professionals.

What the applicants think will be hard or enjoyable about working with the child’s parents, other extended family members, DHS, and service providers.

Culture.

Discuss the applicant’s ability to be culturally receptive to children from a different cultural background than their own, if a child from another culture is placed with them.

Describe how the applicants will care for a child to maintain their connections to their culture and heritage, and helps the child to feel positive about their cultural identity.

Religion and faith. If applicable, describe:

The religion the applicants are affiliated with.

The applicant’s religious expectations of a foster or adoptive child. (A foster child cannot be required to attend their faith service.)

The applicant’s willingness to allow a foster or adoptive child to continue practicing their own religion or not to practice any religion.

Home safety and environment inside and outside.

Describe general characteristics of the residence and neighborhood.

Does the applicant use well water and require an alternative source.

Address any pets or animals living in the home or outside (species and breed), current vaccinations. Describe the pet’s background and any biting and any history of aggression towards people. Describe how foster children will be introduced to pets to minimize risk of aggression.

Describe where medicines and poisonous substances are stored.

Describe what weapons or firearms the applicants have, where they are stored, and the rule requirements, including safety planning, regarding them, if applicable.

Describe how they will monitor children using the Internet and social media.

Note the location of smoke detectors and carbon monoxide detectors.

Describe and discuss any safety hazards such as roads, bodies of water, swimming pools and the accessibility to children. Describe any barriers to the children’s accessibility and safety plans in regards to them.

Note if the applicants have a valid driver’s license and car insurance. Make a copy of the license and insurance.

Describe how the applicants will participate in transporting a child to visits, appointments, school activities, etc.

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Review with the applicants that:

• Motor vehicles used to transport foster children shall not contain a loaded gun and any ammunition in the vehicle shall be kept in a separate, locked container;

• Any motor vehicles used to transport foster children shall be smoke-free when foster children are present; smoking is also prohibited in the foster home when the foster child is present;

• Ensure that appropriate child safety restraints required by law, are used for foster children while being transported in a motor vehicle;

Describe weather-related, accident, medical, and other safety planning.

Ask if they have anything else they would like to share and include this information in the home study.

Renewal Home Study

If this is a renewal foster or adoptive home study, describe in the home study:

Any changes in the household composition (include children placed in the home).

The foster or adoptive parent’s interactions and relationship with the biological parents of any foster or adoptive children in the home.

Any changes in the physical structure of the home.

Describe the foster or adoptive parent’s discipline and behavior strategies used.

When applicable, describe the foster or adoptive children’s connections to birth family and siblings (visits, calls, etc.).

Describe the current foster children’s normalcy activities.

Strengths, skills, weaknesses, needs, and supports of the foster or adoptive parents.

Note any corrective action plans in the last licensing period; significant challenges or concerns which emerged in the home during the previous licensing year, or with biological parents or caseworker, and how they were addressed.

Physical health concerns of the foster or adoptive parents.

Significant financial issues that occurred during the year.

Note if foster parent received notices of court hearings and reviews.

If they attended any court hearings and family team meetings.

Training completed and discussion of training needed for the upcoming license year.

Training needs and training resources available.

Safety plans used.

Discuss any changes for the ages, behaviors, medications, or number of children the family can care for.

Contact at least one collateral source, such as the DHS social work case manager, support staff, teachers, therapist, and providers, for their perspective on how the foster or adoptive children are doing in the home.

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Summary of Consultation and Interviews

Three interviews are required and two of these interviews are required to be in-home for initial licensure or adoption approval. Dates of home visits and who was present: Dates of phone contacts with the family:

References

Dates and description of the three references provided by the applicant and, for foster family applicants, the three unsolicited references to complete the initial home study. Dates and description of reference contacts for renewal study, if any.

Record Checks

Note the dates the checks were completed. Note if an evaluation was completed and the date. Document if no household members resided out of Iowa in the last five years.

Summary and Recommendations

Summarize your overall assessment of how you think the family will do.

Recommendation: Through this home study, this family is recommended for _____ number of children unless there is a sibling group. This family will do best with

Completion and Signatures

Signature of Worker Completion Date

Child Placing Agency Phone Number

Signature of Supervisor Review Date



Chapter B: Foster Family Home Licensing Appendix Resource Parent Home Study Revised February 10, 2017 470-5436

Resource Parent Home Study, Form 470-5436

Purpose The Resource Parent Home Study provides an outline for formatting the narrative evaluation of a prospective foster or adoptive home.

Source Print copies of form 470-5436 from the sample in the manual as needed.

Completion The recruitment and retention home study worker shall:

♦ Complete this form before preparing the licensing or approval recommendation; and

♦ Complete an update of this form when significant changes occur.

NOTE: If an approved home study is more than one year old, then an update is required.

Distribution The recruitment and retention contractor:

♦ Sends the original to the Department for the licensing file. ♦ Keeps a copy for its file. ♦ Gives a copy to the family upon request.

Data The Resource Parent Home Study format includes sections summarizing the following:

♦ The dates of training and family consultations

♦ The family’s motivation for becoming a foster family

♦ The family’s strengths and needs relative to the skills needed

♦ The family’s commitment to safety

♦ A summary of references

♦ The family’s willingness to work with the child’s birth family

♦ The family’s understanding and support of concurrent planning

♦ Plans for supporting the family after placement

♦ Placement recommendations for this family

♦ Signatures, titles, address, and phone number for the worker that prepared the home study




Chapter B: Foster Family Home Licensing Appendix Strengths/Needs Worksheet… Revised February 10, 2017 470-4021 or 470-4021(S)

Strengths/Needs Worksheet – After Meetings 1 and 2, Form 470-4021 or 470-4021(S)

Purpose Form 470-4021 or 470-4021(S) is used to help families assess their willingness and ability to be foster families.

Source Print this form as needed from the sample in the manual.

Completion The PS-MAPP leader asks foster parent applicants to complete this worksheet after meeting 2 during the foster home licensing process.

Distribution The completed form is returned to the recruitment and retention contractor. The form is included with the home study report and is retained in the licensing file. The contractor keeps a copy for the family’s file.

Data The form includes sections for the applicants to report their strengths and needs in relation to:

♦ Communicating effectively ♦ Knowing the children ♦ Building their strengths and meeting their needs





Chapter B: Foster Family Home Licensing Appendix Strength/Needs Worksheet… Revised February 10, 2017 470-4089 or 470-4089(S)

Strength/Needs Worksheet – After Meetings 3 and 4, Form 470-4089 or 470-4089(S)


Source Print supplies of these forms as needed from the samples in the manual.



Data The form includes sections for the applicant to report strengths and needs in relation to:

♦ Know your family ♦ Communicate effectively ♦ Know the children ♦ Build strengths; meet needs ♦ Work in partnership ♦ Be loss and attachment experts





Chapter B: Foster Family Home Licensing Appendix Strengths/Needs Worksheet… Revised February 10, 2017 470-4090 or 470-4090(S)

Strength/Needs Worksheet – After Meeting 5, Form 470-4090 or 470-4090(S)






♦ Know your family ♦ Communicate effectively ♦ Know the children ♦ Build strengths; meet needs ♦ Work in partnership ♦ Be loss and attachment experts ♦ Manage behaviors ♦ Build self-esteem ♦ Assure health and safety





Chapter B: Foster Family Home Licensing Appendix Strength/Needs Worksheet… Revised February 10, 2017 470-4091 or 470-4091(S)

Strength/Needs Worksheet – After Meetings 6 and 7, Form 470-4091 or 470-4091(S)

Purpose Form 470-4091 or 470-4091(S) is used to help families assess their willingness and ability to be foster parents.


Completion The PS-MAPP leader asks foster parent applicants to complete this worksheet after meeting 7 during the foster licensing home study process.



♦ Know your family ♦ Communicate effectively ♦ Know the children ♦ Build strengths; meet needs ♦ Work in partnership ♦ Be loss and attachment experts ♦ Manage behaviors ♦ Build connections ♦ Build self-esteem ♦ Assure health and safety ♦ Assess impact ♦ Make an informed decision





Chapter B: Foster Family Home Licensing Appendix Strengths/Needs Worksheet for… Revised February 10, 2017 470-4024 or 470-4024(S)

Strengths/Needs Worksheet for Fertility Issues, Form 470-4024 or 470-4024(S)

Purpose Form 470-4024 or 470-4024(S) is used to help families who have experienced a loss of fertility to assess their willingness and ability to be foster families.


Completion The PS-MAPP leader asks foster parent applicants to complete the worksheet after the third meeting when the family has not been able to conceive or has experienced the loss of a child.


Data The form includes sections for the applicants to evaluate and report strengths and needs in relation to 14 tasks involved in fostering a child.



iowa department of human servicesdhs.iowa.gov/sites/default/files/12-b-a50.pdf · strength/needs...

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