TITLE IV-E FOSTER CARE ELIGIBILITY REVIEW CHECKLIST

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(June 2000)

CHILD eligible for entire sample review period: YES_______________ NO_______________

PROVIDER eligible for entire sample review period: YES_______________ NO_______________

TITLE IV-E FOSTER CARE ELIGIBILITY REVIEW CHECKLIST

EACH QUESTION MUST BE ANSWERED. If the question is not applicable, check the N/A column. A question with no space for N/A must be answered YES or NO. REview the INSTRUCTIONS FOR COMPLETTING THE TITLE IV-E FOSTER CARE ELIGIBILITY CHECKLIST for an explanation of each question and how to answer it. This form may be annotated with additional information regarding eligibility, as neccessary.

Sample Review period: ____________________ - ________________

1. State Abbrevation and Random Sample Selection number _____ _____ _____ 2. Case ID:_____________

3. County or Local Office: _____________________________ 4. Date of Review (MM/DD/YY): ____________

5. Reviewed by: _________________________________________________

A. CHILD INFORMATION	YES	NO	N/A
X1. Childs Name:
6. Childs Date of Birth (MM/DD/YY):
7. Childs age as of first day of sample review period:
8. If this child was 18 during the sample review period, was (s)he a full time student in secondary school or its equivalent and expecting to graduate prior to the 19^th birthday’ (State Option)
B. RELEVANT DATES
9. Date child was removed from home: (MM/DD/YY)_________________
10. Date court order removing child from home was initiated (i.e., date that petition was filed) (MM/DD/YY):_________________
C. REMOVAL PURSUANT TO A COURT ORDER
11. Was child's removal the result of a judicial determination’ If NO, go to Question #14. If YES, proceed to Question #12.
12. Date of court order removing child from the home (MM/DD/YY): ________________
12 (a). CONTRARY TO THE WELFARE’
13. Is there a court order that addresses REASONABLE EFFORTS TO PREVENT REMOVAL OR REASONABLE EFFORTS TO REUNIFY CHILD AND FAMILY’
13 (a). Date of court order re: reasonable efforts to prevent removal(MM/DD/YY):_______________
13 (b). Date of court order re: reasonable efforts to reunify (MM/DD/YY):_________________
D. VOLUNTARY PLACEMENTS
14. Was the child's removal pursuant to a voluntary placement agreement’ If NO, go to Question #17. If YES, proceed to Question #15.
15. Was the voluntary placement agreement signed by parent/legal guardian AND the agency representative(s)’
15(a). Date voluntary placement agreement was signed by all parties (MM/DD/YY):_____________
16. Is there a judicial determination regarding the child's BEST INTEREST within 180 days of the date of placement’
16 (a). Date of judicial determination (MM/DD/YY): _________________
E. ONGOING JUDICIAL ACTIVITY
17. Is there a judicial determination regarding REASONABLE EFFORTS TO FINALIZE THE PERMANENCY PLAN within 12 months of the date the child is considered to have entered foster care’
17 (a). Date of judicial determination (MM/DD/YY):___________________
18. Is there a subsequent judicial determination regarding REASONABLE EFFORTS TO FINALIZE THE PERMANENCY PLAN at least once within each 12-month period following the initial determination’
18 (a). Date(s) of subsequent judicial determination (MM/DD/YY): __________________
F. AFDC ELIGIBILITY
19. Date child last lived with parent/specified relative prior to current foster care episode (MM/DD/YY)____________
20. Was the child living with the specified relative at #19, above, within 6-months of the initiation of court proceedings or the voluntary placement agreement’
21. Was the child living with and removed from the same specified relative’
22. Has the State determined that the child was AFDC-eligible at the time of removal’
a. Was financial need established’
b. Was deprivation of parental support or care established’
23. Was the child's eligibility redetermined’ a. Date of redetermination, if applicable (MM/DD/YY): _________________
24. Does financial need exist throughout the entire review period’ If NO, indicate period of time during which child's financial need does not exist: FROM: (MM/DD/YY)______________ TO: (MM/DD/YY)________________
25. Does deprivation exist throughout the entire review period’ If NO, indicate period of time during which child is not deprived of parental support or care: FROM: (MM/DD/YY)______________ TO: (MM/DD/YY)_________________
G. STATE AGENCY RESPONSIBILITY FOR PLACEMENT/CARE OF CHILD
26. For the entire time that the child is in an out-of-home placement during the review period, does the IV-E agency (or public agency with IV-E agreement) maintain responsibility for the placement and care of the child’ If YES, proceed to #28. If NO, proceed to #27.
27. Record any portion of the review period in which the agency DOES NOT have responsibility for the placement and care of the child, and complete #28. _______________________
28. Name of agency:
H. PLACEMENT IN LICENSED HOME OR FACILITY (Complete for EVERY home/facility during the review period)
X3. Provider Name:
X4. Provider Street Address:
X5. Provider City: X6. Provider State:
29. Date of child's placement in this foster care facility (MM/DD/YY):
30. Date of childs departure from this facility, if applicable (MM/DD/YY):
31. Type of foster care facility (check one): FFH ( ) GH ( ) Public Inst. ( ) PNP/FP Inst. ( ) Other ( )
32. Is this provider licensed or approved during the child's placement that falls within the period under review’
32 (a). Licensed period from (MM/DD/YY) to (MM/DD/YY)
32 (b). If NO, indicate dates when facility IS NOT licensed/approved: (MM/DD/YY)__________________
I. SAFETY REQUIREMENTS OF PROVIDER (Complete for EVERY home/facility during the review period)
33. Has this State opted out of the criminal records check requirement’ (This requirement applies only to foster family homes and pre-adoptive homes.) If YES, proceed to #35. If NO, continue with #34.
34. Was a criminal records check satisfactorily completed on the foster/adoptive parent(s)’
35. If the State has opted out of the criminal records check requirement, does the licensing file contain documentation that safety considerations with respect to the caretaker(s) have been addressed’
36. If the child is placed in a child care institution, does the licensing file contain documentation that safety considerations with respect to the staff/caretakers have been addressed’
*ADDITIONAL NOTES/COMMENTS*:

Attachment:

Instructions for Completing the Title IV-E Foster Care Eligibility Checklist