Free 17769.FH11 - Indiana

RECOMMENDATION FOR FOSTER FAMILY HOME CARE LICENSE OR RELATIVE HOME CARE LICENSE
State Form 17769 (R7/01-04 ) / FPP 0335

Family and Social Services Administration Division of Family and Children 402 West Washington Street, Room W364, MS08 Indianapolis, Indiana 46204

INSTRUCTIONS: 1. Complete 2 copies. KEEP 1 COPY FOR YOUR AGENCY RECORD. 2. Send original recommendation to FSSA, Division of Family and Children. 3. Copy of approval of recommendation will be returned to county or private agency. 4. Copy will be filed in the license file.
1. Foster Family home license recommendation

b. Special Needs Foster Family Home APR (1) JUL (2)

a. Regular Foster Family Home c. Theraputic Foster Family Home OCT (3) JAN (4)

Relative Home
a. IVE b. Non - IVE

Evaluation:

New Renewal Revised Deny / Revoke Suspend Close

Quarter to which license / approval is being assigned:

Expiration date / renewal date of current license (month, day, year) (not applicable if new evaluation)

CENTRAL OFFICE / COUNTY USE ONLY Enter resource ID number assigned by the Indiana Child Welfare Information System (ICWIS). If the number is less than 9 digits, use zeros for first spaces. GENERAL APPLICANT INFORMATION
Name of agency Complete address of agency (Indiana county offices may omit) Surname of foster family / relative City of foster family / relative home Full name of Applicant A: Occupation Full name of Applicant B: Occupation Marital status Social Security number Marital status Social Security number Street address of foster family / relative home (location address is required for license) ZIP code of foster family / relative home County of foster family / relative home Telephone number of foster family / relative home Date of birth (month, day, year) Race Date of birth (month, day, year) Race

OTHER HOUSEHOLD MEMBERS. DO NOT LIST FOSTER CHILD(REN) FOR REASONS OF CONFIDENTIALITY NAME OF HOUSEHOLD MEMBER (LIST ALL OTHER MEMBERS IN HOME) RELATIONSHIP TO APPLICANT DATE OF BIRTH (month, day, year) UNDER 18 (Y/N) UNDER 6 (Y/N)

No No

No No

No No No No

No No No No No No
No
SUMMARY OF HOUSEHOLD AND FOSTER FAMILY HOME LICENSING CAPACITY
Number of household children under age eighteen (18). Number of foster children under age eighteen (18) for license. Total number of household children plus foster children. Number of household children under age six (6). Number of foster children under age six (6) for license (limit is 4). Total number of household children and foster children under the age of six (6). (RECOMMENDATION CONTINUES ON THE REVERSE SIDE)

No No No No No No
No

NAMES / DATE OF BIRTH OF CHILDREN IN RELATIVE HOME FOR IV-E-FC:

LICENSING AGENCY RECOMMENDATION TO LICENSE
Original application filed (month, day, year) Current application filed (month, day, year) Day care license number (if applicable)

TO BE COMPLETED BY COUNTY OR PRIVATE AGENCY Initial Homestudy Assessment YES NO Annual Relicensing Reapproval Assessment (check one) YES NO Application for foster family home license approved? YES NO Relative home (IV-E or Non-IVE) license approved? YES NO Use / purpose: Regular? YES NO Intermediate or emergency care? YES NO Special needs? YES NO Therapeutic home? YES NO Handicapped, mentally retarded children accepted? YES NO Relative only? YES NO WATER ANALYSIS APPROVAL ON FILE? YES NO SMOKE ALARM RECOMMENDED BY YES NO FAMILY CASE MANAGER? If YES, attach signed, dated Physical Environment Checklist APPLICANT'S STATEMENT OF ATTESTATION? YES NO CHILD PROTECTION SERVICES CHECK COMPLETED? YES NO CRIMINAL HISTORY CHECK COMPLETED? YES NO COUNTY OR PRIVATE AGENCY SPECIAL LICENSING RECOMMENDATIONS OR REQUESTS RECOMMENDATION PROBATIONARY LICENSE IS REQUIRED? YES (Documentation is attached citing the violation and YES referencing the applicable rule?) EXCEPTION,WAIVER OR VARIANCE REQUEST SUBMITTED TO CENTRAL OFFICE LICENSING MANAGER? YES 470 IAC __________________ IC 12-17 __________________ NO NO NO

COMMENT OR EXPLANATION Date of assessment: Date of assessment: Date of assessment: Date of assessment:

N/A

Date approved: Date Checklist completed: ________________

Date of statement: ___________ Date of check: ___________ Date of check: _____________________ FSSA / DFC ACTION

SIGNATURE

APPROVAL DATE

NONAPPROVAL DATE

OTHER CONDITIONS? YES NO (Explain) FIRST AID COMPLETED? YES NO REQUIRED INITIAL FOSTER PARENT/RELATIVE Applicant A: __________ Date completed __________ Applicant B: __________ Date completed __________ TRAINING HOURS COMPLETED ARE: Applicant A: __________ Date completed __________ CONTINUING ANNUAL FOSTER PARENT/RELATIVE Applicant B: __________ Date completed __________ TRAINING HOURS COMPLETED ARE: The above-named applicants for foster family home licensure or relative home licensure have met the requirements as contained in 470 IAC and IC 12-17.44. A signed application for a foster family home or relative home license and a foster family / relative home preparation and assessment are complete and on file in the agency.
Signature of licensing family case manager: Signature of county agency or private agency executive designated to authorize recommendations to FSSA / DFC: Date: Date:

LICENSING AGENCY RECOMMENDATION TO DENY APPLICATION, REVOKE LICENSE, SUSPEND LICENSE / APPROVAL, OR CLOSE CASE FILE FSSA ACTION: 1. Deny application - Reason: 470 IAC (Attach documentation) 2. Revoke a license / approval - Reason: 470 IAC (Attach documentation) 3. Suspend license / approval - Reason: 470 IAC (Attach documentation) 4. Case file closed - Reason: (Check one) A. Voluntary Withdrawal B. Transfer to ________________ (list agency) C. Relocation D. Failure to Respond E. Other ________________
The above-named home applicants for foster family home licensure / relative home licensure have not met the requirements as contained in 470 IAC and IC 12-17.4-4. Signature of county agency or private agency executive designated to authorize recommendations to FSSA / DFC: Date:

ACTION OF THE FAMILY AND SOCIAL SERVICES ADMINISTRATION FSSA action date: Entered by:
Signature of Deputy Director, Division of Family and Children Effective date Expiration date