DCFS Foster and Relative Home Placement Checklist Instructions
This form contains 230 fields organized into 47 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agency Supervision Question | ||
| Agency Supervises Home (Yes) | Checkbox |
Check this box if your agency or region supervises the licensed home in which the placement is being sought. Fill only if 'Seeking placement in licensed foster home: Yes' is 'Yes'.
Depends on:
Seeking placement in licensed foster home: Yes
|
| Agency Supervises Home (No) | Checkbox |
Check this box if your agency or region does not supervise the licensed home in which the placement is being sought. Fill only if 'Seeking placement in licensed foster home: Yes' is 'Yes'.
Depends on:
Seeking placement in licensed foster home: Yes
|
| Authorization Information | ||
| PCD Clearance Number | Text |
Enter the PCD Clearance number. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Authorization Date and Time | Text |
Provide the date and time of the authorization. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Staff ID | Text |
Enter the Staff ID responsible for the authorization. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Capacity Calculation | ||
| Maximum Capacity | Number |
Provide the maximum capacity of the home as determined by the capacity chart. Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
|
| Total Children Under 18 | Number |
Provide the total number of children under 18 years of age currently in the home. Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
|
| Space Available | Number |
Provide the number representing the available space for additional placements. Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
|
| Caregiver Awareness of Placement Restrictions | ||
| YES | Checkbox |
Check this box if the caregiver is aware of any 'holds' or restrictions on placements in their home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| NO | Checkbox |
Check this box if the caregiver is NOT aware of any 'holds' or restrictions on placements in their home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Caretaker Ability for Placement | ||
| Caretaker Able for Placement - Yes | Checkbox |
Check this box if the caretaker is able to care for the needs and manage the behavior of the child(ren) proposed for placement. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Caretaker Able for Placement - No | Checkbox |
Check this box if the caretaker is not able to care for the needs and manage the behavior of the child(ren) proposed for placement. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Children In Home Details | ||
| Total Children in Home | Text |
Please enter the total number of children under the age of 18 currently residing in the home, including foster, biological, adoptive, and guardianship children. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| YES | Checkbox |
Check this box if any of the children currently residing in the home have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| NO | Checkbox |
Check this box if none of the children currently residing in the home have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Children with Special Needs Count | Text |
Please enter the number of children in the home who have special needs. Fill only if 'YES' is 'Yes'.
Depends on:
YES
|
| Children Under Age Six | Text |
Please enter the number of children in the home who are under six years of age. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Children Under Age Two | Text |
Please enter the number of children in the home who are under two years of age. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Unrelated Children in Home | Text |
Please enter the number of unrelated children currently residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Child's Information | ||
| Fifth Child's Name | Text |
Enter the full name of the fifth child to be placed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Child's CYCIS ID | Text |
Enter the CYCIS identification number for the fifth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Child's Date of Birth | Date |
Enter the date of birth for the fifth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Child's Age | Text |
Enter the current age of the fifth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Child's SSN | Text |
Enter the Social Security Number for the fifth child if they are 13 or older. Fill only if 'Fifth Child's Age' is 13 or older.
Depends on:
Fifth Child's Age
|
| Special Needs Yes | Checkbox |
Check this box if the fifth child has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs No | Checkbox |
Check this box if the fifth child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Supervision Plan Yes | Checkbox |
Check this box if a supervision plan is required for the fifth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Supervision Plan No | Checkbox |
Check this box if a supervision plan is not required for the fifth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Foster Child Information | ||
| Fifth Foster Child Name | Text |
Enter the full name of the fifth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Foster Child Date of Birth | Date |
Provide the date of birth for the fifth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Foster Child Age | Text |
Enter the current age of the fifth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Foster Child SSN | Text |
Provide the Social Security Number for the fifth foster child if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs Yes | Checkbox |
Check this box if the fifth foster child has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs No | Checkbox |
Check this box if the fifth foster child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Individual (18+) Information | ||
| Fifth Individual Name | Text |
Enter the full legal name of the fifth individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Individual Other Names | Text |
Provide any other names, including maiden names or aliases, used by the fifth individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Individual Date of Birth | Date |
Enter the date of birth for the fifth individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Individual SSN | Text |
Enter the Social Security Number for the fifth individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Other Child Information | ||
| Fifth Other Child's Name | Text |
Enter the full name of the fifth other child residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Other Child's AKA or Other Names | Text |
Enter any 'also known as' (AKA) or other names used by the fifth other child residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Other Child's Relationship to Foster Parent | Text |
Enter the relationship of the fifth other child to the foster parent. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Other Child's Date of Birth | Date |
Enter the birth date of the fifth other child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fifth Other Child's SSN (13 & Older) | Text |
Enter the Social Security Number of the fifth other child, if applicable and if the child is 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs YES | Checkbox |
Check this box if the fifth other child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs NO | Checkbox |
Check this box if the fifth other child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Child's Information | ||
| First Child's Name | Text |
Enter the full name of the first child to be placed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Child's CYCIS ID | Text |
Enter the CYCIS ID for the first child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Child's Date of Birth | Date |
Provide the date of birth for the first child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Child's Age | Text |
Enter the current age of the first child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Child's SSN | Text |
Provide the Social Security Number for the first child, if applicable and 13 years or older. Fill only if 'First Child's Age' is 13 or older.
Depends on:
First Child's Age
|
| Check Box15 | CheckBox | |
| Check Box15_No | CheckBox | |
| Check Box16 | CheckBox | |
| Check Box16_No | CheckBox | |
| First Foster Child Information | ||
| Text64 | Text | |
| Text65 | Text | |
| Text66 | Text | |
| Text67 | Text | |
| Check Box68 | CheckBox | |
| First Child Special Needs No | Checkbox |
Check this box if the first foster child listed in the table does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Individual (18+) Information | ||
| First Individual's Name | Text |
Enter the full legal name of the first individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Individual's Other Names | Text |
Enter any other names, including maiden names or aliases, used by the first individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Individual's Date of Birth | Date |
Enter the date of birth for the first individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Individual's SSN | Text |
Enter the Social Security Number for the first individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child Information | ||
| First Other Child Name | Text |
Enter the full legal name of the first other child residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child AKA or Other Names | Text |
Enter any alternative names or aliases by which the first other child is known. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child Relationship to Foster Parent | Text |
Enter the relationship of the first other child to the foster parent. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child Date of Birth | Date |
Enter the date of birth for the first other child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child SSN | Text |
Enter the Social Security Number of the first other child, if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child Special Needs - Yes | Checkbox |
Check this box if the first other child listed in this section has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| First Other Child Special Needs - No | Checkbox |
Check this box if the first other child listed in this section does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Foster Care License Inquiry | ||
| Foster Care License YES | Checkbox |
Check this box if the home has a foster care license. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Foster Care License NO | Checkbox |
Check this box if the home does not have a foster care license. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Foster Home License Details | ||
| Caretaker holds DCFS foster care home license - Yes | Checkbox |
Check this box if the caretaker holds a DCFS foster care home license. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Caretaker holds DCFS foster care home license - No | Checkbox |
Check this box if the caretaker does not hold a DCFS foster care home license. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Supervising Agency | Text |
Please provide the name of the agency that currently supervises the foster home license. Fill only if 'Caretaker holds DCFS foster care home license - Yes' is 'Yes'.
Depends on:
Caretaker holds DCFS foster care home license - Yes
|
| Licensed Capacity | Number |
Please enter the licensed capacity of the foster home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Licensed Age Range | Text |
Please enter the licensed age range for children in the foster home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Home licensed for related and unrelated children - Yes | Checkbox |
Check this box if the home is licensed to care for both related and unrelated children. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Home licensed for related and unrelated children - No | Checkbox |
Check this box if the home is not licensed to care for both related and unrelated children. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Foster Parent Contact Question | ||
| YES | Checkbox |
Check this box if you have contacted the foster parent or relative caregiver to ensure the placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form.
|
| NO | Checkbox |
Check this box if you have not contacted the foster parent or relative caregiver and need to do so before proceeding.
|
| Foster Parent Information | ||
| Foster Parent Name | Text |
Enter the full name of the foster parent or relative.
|
| Licensed Provider ID | Text |
Provide the licensed provider identification number.
|
| Relationship to Child | Text |
Specify the relationship of the foster parent or relative to the child.
|
| Birth Date | Date |
Enter the birth date of the foster parent or relative.
|
| Social Security Number | Text |
Provide the social security number of the foster parent or relative.
|
| Address | Text |
Enter the complete address of the foster parent or relative.
|
| Fourth Child's Information | ||
| Fourth Child's Name | Text |
Enter the full name of the fourth child to be placed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child's CYCIS ID | Text |
Enter the CYCIS ID for the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child's Date of Birth | Date |
Enter the date of birth for the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child's Age | Text |
Enter the current age of the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child's SSN | Text |
Enter the Social Security Number of the fourth child if they are 13 years or older. Fill only if 'Fourth Child's Age' is 13 or older.
Depends on:
Fourth Child's Age
|
| Fourth Child Special Needs Yes | Checkbox |
Check this box if the fourth child has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child Special Needs No | Checkbox |
Check this box if the fourth child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child Supervision Plan Yes | Checkbox |
Check this box if a supervision plan is required for the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Child Supervision Plan No | Checkbox |
Check this box if a supervision plan is not required for the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Foster Child Information | ||
| Text79 | Text | |
| Fourth Foster Child Date of Birth | Date |
Enter the date of birth for the fourth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Foster Child Age | Text |
Enter the current age of the fourth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Foster Child SSN | Text |
Provide the Social Security Number for the fourth foster child, if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs - Yes | Checkbox |
Check this box if the fourth foster child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs - No | Checkbox |
Check this box if the fourth foster child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Individual (18+) Information | ||
| Fourth Individual Name | Text |
Please provide the full name of the fourth individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Individual AKA or Other Names | Text |
Please provide any "Also Known As," maiden names, or other names used by the fourth individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Individual Date of Birth | Date |
Please provide the date of birth for the fourth individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Individual SSN | Text |
Please provide the Social Security Number (SSN) for the fourth individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Other Child Information | ||
| Fourth Other Child Name | Text |
Enter the full name of the fourth child residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Other Child AKA or Other Names | Text |
Enter any other names or aliases used by the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Other Child Relationship to Foster Parent | Text |
Specify the relationship of the fourth child to the foster parent, such as biological, adopted, or under guardianship. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Other Child Date of Birth | Date |
Enter the date of birth for the fourth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Fourth Other Child SSN | Text |
Enter the Social Security Number of the fourth child, if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs Yes | Checkbox |
Check this box if the fourth other child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs No | Checkbox |
Check this box if the fourth other child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| General | ||
| Text52 | Text | |
| Text53 | Text | |
| Text54 | Text | |
| Text55 | Text | |
| Text56 | Text | |
| Licensed Home Details | ||
| License good for both related and unrelated children - YES | Checkbox |
Check this box if the foster care license permits the care of both related and unrelated children. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| License good for both related and unrelated children - NO | Checkbox |
Check this box if the foster care license does not permit the care of both related and unrelated children. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| Placement within licensed age range - YES | Checkbox |
Check this box if the current child's placement falls within the age range specified by the home's foster care license. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| Placement within licensed age range - NO | Checkbox |
Check this box if the current child's placement does not fall within the age range specified by the home's foster care license. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| Number of Foster Children in Home | ||
| Number of Foster Children | Text |
Enter the total number of foster children currently residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Number of Other Children Under 18 | ||
| Other Children Under 18 Count | Text |
Please provide the total number of other children under the age of 18 currently residing in the home, including biological children, adopted children, and children under foster parent's guardianship. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Permitted Gender of Children for Placement | ||
| Male Only | Checkbox |
Check this box if only male children are permitted for placement. Fill only if 'Supervision Plan Yes', 'Permit Additional Children Yes' is 'Yes' for all.
Depends on:
Supervision Plan Yes, Permit Additional Children Yes
|
| Female Only | Checkbox |
Check this box if only female children are permitted for placement. Fill only if 'Supervision Plan Yes', 'Permit Additional Children Yes' is 'Yes' for all.
Depends on:
Supervision Plan Yes, Permit Additional Children Yes
|
| Both | Checkbox |
Check this box if both male and female children are permitted for placement. Fill only if 'Supervision Plan Yes', 'Permit Additional Children Yes' is 'Yes' for all.
Depends on:
Supervision Plan Yes, Permit Additional Children Yes
|
| Placement Gender Options | ||
| Male Only | Checkbox |
Check this box if only male children can be placed in the home. Fill only if 'YES' is 'Yes'.
Depends on:
YES
|
| Female Only | Checkbox |
Check this box if only female children can be placed in the home. Fill only if 'YES' is 'Yes'.
Depends on:
YES
|
| Both | Checkbox |
Check this box if both male and female children can be placed in the home. Fill only if 'YES' is 'Yes'.
Depends on:
YES
|
| Placement Seeking Question | ||
| Seeking placement in licensed foster home: Yes | Checkbox |
Check this box if you are seeking placement in a licensed foster home.
|
| Seeking placement in licensed foster home: No | Checkbox |
Check this box if you are not seeking placement in a licensed foster home.
|
| Second Child's Information | ||
| Second Child's Name | Text |
Enter the full name of the second child to be placed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child's CYCIS ID | Text |
Enter the CYCIS identification number for the second child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child's Date of Birth | Date |
Enter the date of birth for the second child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child's Age | Text |
Enter the current age of the second child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child's SSN | Text |
Enter the Social Security Number for the second child, if applicable and 13 years or older. Fill only if 'Second Child's Age' is 13 or older.
Depends on:
Second Child's Age
|
| Second Child Special Needs (Yes) | Checkbox |
Check this box if the second child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child Special Needs (No) | Checkbox |
Check this box if the second child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child Supervision Plan (Yes) | Checkbox |
Check this box if a supervision plan is required for the second child listed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Child Supervision Plan (No) | Checkbox |
Check this box if a supervision plan is not required for the second child listed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Foster Child Information | ||
| Second Foster Child Name | Text |
Enter the full name of the second foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Foster Child Date of Birth | Date |
Provide the birth date of the second foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Foster Child Age | Text |
Enter the current age of the second foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Foster Child SSN | Text |
Enter the Social Security Number for the second foster child, if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Foster Child Special Needs - Yes | Checkbox |
Check this box if the second foster child has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Foster Child Special Needs - No | Checkbox |
Check this box if the second foster child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Individual (18+) Information | ||
| Second Individual Name | Text |
Enter the full name of the second individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Individual AKA/Maiden Name | Text |
Enter any other known names, including maiden names or aliases, for the second individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Individual Date of Birth | Date |
Enter the date of birth for the second individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Individual SSN | Text |
Enter the Social Security Number for the second individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Other Child Information | ||
| Second Other Child Name | Text |
Enter the full name of the second child residing in the home who is under 18. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Other Child AKA or Other Names | Text |
Enter any 'also known as' names or other names for the second child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Other Child Relationship to Foster Parent | Text |
Enter the relationship of the second child to the foster parent. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Other Child Date of Birth | Date |
Provide the date of birth for the second child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Second Other Child SSN | Text |
Enter the Social Security Number for the second child if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs - YES | Checkbox |
Check this box if the second other child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs - NO | Checkbox |
Check this box if the second other child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Child's Information | ||
| Text45 | Text | |
| Text46 | Text | |
| Text47 | Text | |
| Text48 | Text | |
| Text49 | Text |
Depends on:
Text48
|
| Check Box50 | CheckBox | |
| Sixth Child Special Needs No | Checkbox |
Check this box if the sixth child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Child Supervision Plan Yes | Checkbox |
Check this box if a supervision plan is in place for the sixth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Child Supervision Plan No | Checkbox |
Check this box if a supervision plan is not in place for the sixth child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Foster Child Information | ||
| Sixth Foster Child Name | Text |
Enter the full name of the sixth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Foster Child Date of Birth | Date |
Enter the date of birth for the sixth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Foster Child Age | Text |
Enter the current age of the sixth foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Foster Child SSN | Text |
Enter the Social Security Number (SSN) of the sixth foster child if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Foster Child Special Needs: Yes | Checkbox |
Check this box if the sixth foster child has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Foster Child Special Needs: No | Checkbox |
Check this box if the sixth foster child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Individual (18+) Information | ||
| Individual Name | Text |
Please enter the full name of the individual. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| AKA or Other Names | Text |
Please enter any other names by which the individual is known, such as maiden names or aliases. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Date of Birth | Date |
Please enter the individual's date of birth. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Social Security Number | Text |
Please enter the individual's Social Security Number. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Other Child Information | ||
| Sixth Other Child Name | Text |
Provide the full name of the sixth other child residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Other Child AKA or Other Names | Text |
Provide any other names or aliases used by the sixth other child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Other Child Relationship to Foster Parent | Text |
State the relationship of the sixth other child to the foster parent. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Other Child Date of Birth | Date |
Enter the date of birth for the sixth other child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Sixth Other Child SSN | Text |
Provide the Social Security Number (SSN) for the sixth other child if they are 13 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs YES | Checkbox |
Check this box if the sixth other child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs NO | Checkbox |
Check this box if the sixth other child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Space Availability Calculation | ||
| Licensed Capacity | Number |
Please enter the maximum number of children the home is licensed to care for. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| Number of Foster Children in Home | Number |
Please enter the current number of foster children residing in the home. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| Space Available | Number |
Please enter the calculated amount of space available for additional placements. Fill only if 'Foster Care License YES' is 'Yes'.
Depends on:
Foster Care License YES
|
| Special Needs Care Inquiry | ||
| Special Needs Care: Yes | Checkbox |
Check this box if the foster parent or relative can care for the child's special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Special Needs Care: No | Checkbox |
Check this box if the foster parent or relative cannot care for the child's special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Supervision and Placement Plan | ||
| YES | Checkbox |
Check this box if there is a supervision plan in place for any child in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| NO | Checkbox |
Check this box if there is no supervision plan in place for any child in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Other Children Placed | Text |
Indicate how many other children can be placed in the home. Fill only if 'YES' is 'Yes'.
Depends on:
YES
|
| Age for Placement | Text |
Specify the age of the child that can be placed in the home. Fill only if 'YES' is 'Yes'.
Depends on:
YES
|
| Supervision Plan | ||
| Supervision Plan Yes | Checkbox |
Check this box if there is a written supervision plan in place for any child in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Supervision Plan No | Checkbox |
Check this box if there is no written supervision plan in place for any child in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Permit Additional Children Yes | Checkbox |
Check this box if the supervision plan permits additional children to be placed in the home. Fill only if 'Supervision Plan Yes' is 'Yes'.
Depends on:
Supervision Plan Yes
|
| Permit Additional Children No | Checkbox |
Check this box if the supervision plan does not permit additional children to be placed in the home. Fill only if 'Supervision Plan Yes' is 'Yes'.
Depends on:
Supervision Plan Yes
|
| Allowed Ages for Placement | Text |
Enter the ages of children that are permitted to be placed in the home while the supervision plan is in place. Fill only if 'Supervision Plan Yes', 'Permit Additional Children Yes' is 'Yes' for all.
Depends on:
Supervision Plan Yes, Permit Additional Children Yes
|
| Supervision Plan Description | ||
| Supervision Plan Description | Text |
Provide a detailed description of the supervision plan in place for any child listed above. Fill only if 'Check Box16', 'Second Child Supervision Plan (Yes)', 'Third Child Supervision Plan Yes', 'Fourth Child Supervision Plan Yes', 'Supervision Plan Yes', 'Sixth Child Supervision Plan Yes' is 'Yes' for any.
Depends on:
Check Box16, Second Child Supervision Plan (Yes), Third Child Supervision Plan Yes, Fourth Child Supervision Plan Yes, Supervision Plan Yes, Sixth Child Supervision Plan Yes
|
| Third Child's Information | ||
| Third Child's Name | Text |
Enter the full name of the third child to be placed. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child's CYCIS ID | Text |
Enter the unique CYCIS identification number for the third child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child's Date of Birth | Date |
Enter the date of birth for the third child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child's Age | Text |
Enter the current age of the third child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child's SSN | Text |
Enter the Social Security Number for the third child, if applicable and 13 years or older. Fill only if 'Third Child's Age' is 13 or older.
Depends on:
Third Child's Age
|
| Third Child Special Needs Yes | Checkbox |
Check this box if the third child has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child Special Needs No | Checkbox |
Check this box if the third child does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child Supervision Plan Yes | Checkbox |
Check this box if a supervision plan is required for the third child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Child Supervision Plan No | Checkbox |
Check this box if a supervision plan is not required for the third child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Foster Child Information | ||
| Third Foster Child Name | Text |
Please enter the full name of the third foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Foster Child Date of Birth | Date |
Please enter the date of birth for the third foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Foster Child Age | Text |
Please enter the current age of the third foster child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Foster Child SSN | Text |
Please enter the Social Security Number of the third foster child if they are 13 years or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Foster Child Special Needs YES | Checkbox |
Check this box if the third foster child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Foster Child Special Needs NO | Checkbox |
Check this box if the third foster child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Individual (18+) Information | ||
| Third Individual's Name | Text |
Enter the full legal name of the third individual aged 18 or older residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Individual's Other Names | Text |
Provide any other names, including maiden or 'also known as' names, for the third individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Individual's Date of Birth | Date |
Enter the birth date of the third individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Individual's SSN | Text |
Enter the Social Security Number of the third individual aged 18 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Other Child Information | ||
| Third Other Child Name | Text |
Enter the full name of the third other child residing in the home. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Other Child AKA or Other Names | Text |
Enter any other names or aliases used by the third other child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Other Child Relationship to Foster Parent | Text |
Enter the relationship of the third other child to the foster parent. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Other Child Date of Birth | Date |
Enter the date of birth of the third other child. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
|
| Third Other Child SSN | Text |
Enter the Social Security Number of the third other child, if applicable and if the child is 13 or older. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
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| Special Needs Yes | Checkbox |
Check this box if the third other child listed has special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
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| Special Needs No | Checkbox |
Check this box if the third other child listed does not have special needs. Fill only if 'Did you contact the foster parent or relative caregiver to ensure that this placement is appropriate within DCFS placement guidelines and to secure answers to the remaining questions on this form?' is 'Yes'.
Depends on:
YES
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| Unlicensed Home Details | ||
| Placement Safety Checklist Completed Yes | Checkbox |
Check this box if the Placement Safety Checklist (CFS 454) has been completed for the unlicensed home. Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
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| Placement Safety Checklist Completed No | Checkbox |
Check this box if the Placement Safety Checklist (CFS 454) has not been completed for the unlicensed home. Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
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| Relative Agrees to Placement Agreement Yes | Checkbox |
Check this box if the relative agrees to the conditions of the Relative Caregiver Placement Agreement (CFS 458). Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
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| Relative Agrees to Placement Agreement No | Checkbox |
Check this box if the relative does not agree to the conditions of the Relative Caregiver Placement Agreement (CFS 458). Fill only if 'Foster Care License NO' is 'Yes'.
Depends on:
Foster Care License NO
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