Form DCF-043 "Verification of Requirements for Licensure" - Connecticut

What Is Form DCF-043?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-043 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-043 "Verification of Requirements for Licensure" - Connecticut

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Connecticut Department of Children and Families
VERIFICATION OF REQUIREMENTS FOR LICENSURE
DCF-043
6/17 (Rev.)
Page 1 of 4
Parent #1
Parent #2
LAST Name:
FIRST Name:
LAST Name:
FIRST Name:
DOB:
Home Phone:
DOB:
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-mail:
Address: (No. and Street):
City:
State:
Zip:
MAILING Address (If different):
City:
State:
Zip:
LICENSING RECOMMENDATIONS
Application
LINK#:
Select Region:
1
2
3
4
5
6
Dated:
Pre-Service Training:
Begin Date:
End Date:
Adoption
Core Foster Care
Fictive Kin
Independent
Relative
Respite Caregiver
Waiver:
Yes
No.
If yes, please attach the waiver form.
Licensed Bed Capacity:
Race:
Gender:
Age Range:
Select One or Enter your own
Please Select One
For a Kinship, Fictive Kin or Independent Interstate license, names of children in placement and their dates of birth.
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
I/WE AGREE TO REMAIN IN COMPLIANCE WITH THE STATE OF CONNECTICUT FOSTER CARE REGULATIONS
§17a-145-132 Assessment of Foster or Prospective Adoptive Parents and Members of the Household
1.
We have participated in an assessment completed by DCF for each applicant/licensee and all members of the household to
Yes
No
determine the ability of the applicant/licensee to comply with the Regulations of Connecticut State Agencies.
2.
We were given a copy of, read and understand DCF Regulations §§17a-145-130 through 17a-145-160.
Yes
No
§17a-145-137 Physical Requirements of Foster and Prospective Adoptive Homes
1.
My/our dwellings and furnishings are clean, comfortable and in good repair
Yes
No
2.
My/our home is reasonably safe from fire.
Yes
No
3.
My/our home and grounds are reasonably free from anything that constitutes a hazard to children.
Yes
No
Any peeling indoor or outdoor paint accessible to children is non-toxic.
N/A
Yes
No
4.
5.
Any equipment used by the children is free from any paint or other covering material that is poisonous.
Yes
No
Swimming pools and hot tubs comply with local and state regulations.
N/A
Yes
No
6.
7.
All medicines and toxic and flammable materials are kept out of the reach of children
Yes
No
8.
There are sufficient indoor and outdoor space, ventilation, toilet facilities, light and heat to ensure the health and comfort of all
Yes
No
members of the household.
9.
All heating systems comply with state and local building and fire codes.
Yes
No
10. There are adequate sewage and garbage facilities.
Yes
No
11. All power driven machinery or other hazardous equipment is properly safeguarded and, if used by a foster child, the child will be
Yes
No
properly supervised by an adult.
If a furnace is located on the same floor as a living space, it is enclosed..
N/A
Yes
No
12.
13. Smoke detectors are in operating condition and located so as to protect sleep areas, play areas and the basement.
Yes
No
Connecticut Department of Children and Families
VERIFICATION OF REQUIREMENTS FOR LICENSURE
DCF-043
6/17 (Rev.)
Page 1 of 4
Parent #1
Parent #2
LAST Name:
FIRST Name:
LAST Name:
FIRST Name:
DOB:
Home Phone:
DOB:
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-mail:
Address: (No. and Street):
City:
State:
Zip:
MAILING Address (If different):
City:
State:
Zip:
LICENSING RECOMMENDATIONS
Application
LINK#:
Select Region:
1
2
3
4
5
6
Dated:
Pre-Service Training:
Begin Date:
End Date:
Adoption
Core Foster Care
Fictive Kin
Independent
Relative
Respite Caregiver
Waiver:
Yes
No.
If yes, please attach the waiver form.
Licensed Bed Capacity:
Race:
Gender:
Age Range:
Select One or Enter your own
Please Select One
For a Kinship, Fictive Kin or Independent Interstate license, names of children in placement and their dates of birth.
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
Name:
DOB:
I/WE AGREE TO REMAIN IN COMPLIANCE WITH THE STATE OF CONNECTICUT FOSTER CARE REGULATIONS
§17a-145-132 Assessment of Foster or Prospective Adoptive Parents and Members of the Household
1.
We have participated in an assessment completed by DCF for each applicant/licensee and all members of the household to
Yes
No
determine the ability of the applicant/licensee to comply with the Regulations of Connecticut State Agencies.
2.
We were given a copy of, read and understand DCF Regulations §§17a-145-130 through 17a-145-160.
Yes
No
§17a-145-137 Physical Requirements of Foster and Prospective Adoptive Homes
1.
My/our dwellings and furnishings are clean, comfortable and in good repair
Yes
No
2.
My/our home is reasonably safe from fire.
Yes
No
3.
My/our home and grounds are reasonably free from anything that constitutes a hazard to children.
Yes
No
Any peeling indoor or outdoor paint accessible to children is non-toxic.
N/A
Yes
No
4.
5.
Any equipment used by the children is free from any paint or other covering material that is poisonous.
Yes
No
Swimming pools and hot tubs comply with local and state regulations.
N/A
Yes
No
6.
7.
All medicines and toxic and flammable materials are kept out of the reach of children
Yes
No
8.
There are sufficient indoor and outdoor space, ventilation, toilet facilities, light and heat to ensure the health and comfort of all
Yes
No
members of the household.
9.
All heating systems comply with state and local building and fire codes.
Yes
No
10. There are adequate sewage and garbage facilities.
Yes
No
11. All power driven machinery or other hazardous equipment is properly safeguarded and, if used by a foster child, the child will be
Yes
No
properly supervised by an adult.
If a furnace is located on the same floor as a living space, it is enclosed..
N/A
Yes
No
12.
13. Smoke detectors are in operating condition and located so as to protect sleep areas, play areas and the basement.
Yes
No
Page 2 of 4
§17a-145-138 Telephone
1.
There is a working telephone accessible to the children at all times with emergency numbers posted in an easily-visible location.
Yes
No
2.
I/We will notify DCF within one business day of any change in the telephone number or telephone status.
Yes
No
§17a-145-139 Children's Bedroom, Clothing and Privacy
1.
Each bedroom is enclosed on all sides, with a window and a door that lead into a hallway or other common area..
Yes
No
2.
Each bedroom has at least two approved means of exit capable of providing for escape in the event of fire or disaster.
Yes
No
3.
Bedrooms for children are used for sleeping purposes and customary children’s activities only, and are not used for the general
Yes
No
purposes of other members of the family.
Foster children under five years of age sleep on the same floor and in close proximity to foster parents or another
4.
N/A
Yes
No
responsible adult.
5.
There is a separate bed provided for each child. If siblings of the same sex sleep together in a double-sized or larger bed, it will
Yes
No
occur only with the approval of the Commissioner or designee.
No child three years of age or older shall be permitted to share a bedroom with another child of the opposite sex or a
6.
N/A
Yes
No
same sex child of disparate age
7
No child over one year of age shall share a room with an adult without the permission of the Commissioner or designee.
N/A
Yes
No
8
No more than four children including the applicant/licensee’s own children shall sleep in the same room without the
N/A
Yes
No
permission of the Commissioner or designee
9
Children’s clothing will be kept clean and in good condition in keeping with the standards of the community.
Yes
No
10
There is safe storage for children’s clothing and personal possessions.
Yes
No
11
Each child is afforded privacy appropriate to his or her growth and development.
Yes
No
§17a-145-140 Food and Water
1.
All food for human consumption, food storage and preparation, personal cleanliness and general care of the home meet generally-
Yes
No
accepted health standards.
2.
Non-pasteurized milk products will not be provided to any foster child by or with the approval or knowledge of the applicant/licensee.
Yes
No
3.
The water supply is safe and adequate to meet the needs of the household.
Yes
No
§17a-145-141 Firearms and Weapons
Answer if you or any resident in the home possess a firearm or other type of dangerous weapon:
N/A
firearms and ammunition are locked in separate places inaccessible to all children
Yes
No
firearms are equipped with trigger guard locks
Yes
No
other types of dangerous weapons are unstrung or unloaded and stored in locked containers out of the reach of children
Yes
No
keys to the locked storage areas of firearms, other types of dangerous weapons, trigger guards and ammunition are kept in the
Yes
No
secure possession of an adult or are otherwise reasonably secure from children.
§17a-145-142 Animals
All animals are kept in a safe and sanitary manner in compliance with all statutes and regulations regarding vaccinations and
N/A
Yes
No
generally-accepted veterinary care.
§17a-145-143 Health Standards for Foster Parents and Members of the Household
1.
Each person living in the home is in good health, or is receiving all necessary continuing medical care and is free of communicable
Yes
No
disease.
2.
I/We are physically and mentally able to provide care to children.
Yes
No
3.
I/We will notify DCF whenever I/we or a member of the family contract a communicable disease or develop a physical or mental
Yes
No
infirmity which interferes with my/our child caring ability.
§17a-145-144 Character Standards for Foster Parents and Members of the Household
I/We and other members of the household are of good character, habits and reputation.
Yes
No
§17a-145-145 Change in Licensed Conditions
I/We will notify DCF in writing prior to, or not later than one business day, following any change in circumstance or member of the household
which may alter the statement of facts made in the foster care licensing application or which may affect the ability of the applicant/licensee
Yes
No
to provide ongoing care for the child.
§17a-145-146 Reporting of a Fire or the Injury, Illness, Death or Absence of a Child From Placement
I/We will notify DCF by telephone within six hours of any fire in the home, any serious injury or serious illness of a foster child, the death of
Yes
No
any child in the home or any unauthorized absence of a foster child.
§17a-145-147 Financial Condition of the Foster Parent
I/We have an income sufficient to meet the needs of my/our family.
1.
Yes
No
The money received on behalf of the child shall be expended for the care of the child.
2
Yes
No
§17a-145-148 Substitute Childcare
If all adults in the home are employed or otherwise occupied such that they spend a substantial amount of time away from the home, the
care and supervision of the child will be provided by a competent individual and the plans for such care must be approved in advance by the
Yes
No
Commissioner or designee (except consistent with the reasonable and prudent parent standard.)
§17a-145-149 Cooperation with the DCF Case Plan
I/We will comply with the case plan for the child and work cooperatively with DCF in all matters pertaining to the child’s welfare.
Yes
No
1.
I/We will accept, cooperate with and support arrangements made for the child to have contact with, including visits and
2
correspondence, the child’s biological family at the frequency indicated by the Case Plan, and agree that visits may take place at
Yes
No
our home or other location if deemed to be in the best interest of the child and foster family.
Page 3 of 4
§17a-145-150 Limitation on the Number of Licenses or Approvals Allowed
I/We will possess only one license or approval for adoption or other form of out-of-home care.
Yes
No
I/We will not hold dual licensure.
Yes
No
I/We will not accept another child for placement on a private basis.
Yes
No
§17a-145-151 General Requirements of Foster Parents
1., I/We are physically, intellectually and emotionally capable of providing care, guidance and supervision to a child, including:
Yes
No
ensuring routine medical care, scheduling and transportation
Yes
No
obtaining and following instructions from the child’s medical provider for administering medication or treatment
Yes
No
keeping all medications clearly labeled and out of the reach of children
Yes
No
establishing plans to respond to illness and emergencies, including serious injuries and the ingestion of poison, with appropriate
Yes
No
first aid supplies available in the home but out of the reach of children
maintaining all documentation as required by DCF
Yes
No
providing for the child’s physical needs including adequate hygiene; nutritional meals and snacks prepared in a safe and sanitary
manner; readily available drinking water; a balanced schedule of rest, active play and indoor and outdoor activity appropriate to
Yes
No
the age of the child
promoting the social, intellectual, emotional and physical development of the child by providing activities that meet these needs
Yes
No
or any special needs
assuring adequate opportunity for cultural and educational activities in the family and in the community
Yes
No
providing a child who does not share the same language as the caregiver with opportunities to practice his or her native
Yes
No
language as he or she becomes bilingual or multilingual
providing adequate opportunity for religious training and participation appropriate to the child’s religious denomination, if wanted
Yes
No
not requiring any child to participate in religious practices contrary to the child’s beliefs
Yes
No
providing emotional support and an environment that meets the child’s ethnic and cultural needs
Yes
No
assuring the child’s participation in an approved education program, including regular school attendance
Yes
No
cooperating with proper authorities regarding the child’s educational needs
Yes
No
guiding the child in the acquisition of daily living skills, including the assignment of daily chores to the child on the basis of the
Yes
No
child’s abilities and developmental level
providing infants and toddlers with ample opportunity for freedom of movement each day outside of a crib or playpen
Yes
No
holding infants for all bottle feedings, as well as at other times, for attention and verbal communication.
Yes
No
2
I/We, along with members of the household, substitute care providers and other persons having regular access to the children the home shall:
give the child humane and affectionate care
Yes
No
be a positive role model to the child and instruct the child in appropriate behavior
Yes
No
establish limits and assist the child with developing self-control and judgment skills
Yes
No
encourage the child to assume age-appropriate responsibility for his or her decisions and actions.
Yes
No
3
I/We will:
use disciplinary methods appropriate to the child’s age and level of development
Yes
No
not use physically or verbally abusive, neglectful, humiliating, frightening or corporal punishment, including but not limited to
Yes
No
spanking, cursing or threats
obtain prior written approval from the Commissioner or designee when unusual circumstances require continued or frequent use
Yes
No
of physical or mechanical restraints
complete all assessment and training requirements as required by DCF.
Yes
No
§17a-145-152 Criminal History; Pending Criminal Actions; Child Protection History
I/We or any member of my/our household has/have:
been convicted of injury or risk of injury to a minor or other similar offense against a minor
Yes
No
1.
been convicted of impairing the morals of a minor or other similar offense against a minor
Yes
No
2
3
been convicted of a violent crime or similar offense against a person
Yes
No
4
been convicted of the possession, use or sale of a controlled substance within the past five years
Yes
No
5
been convicted of illegal use of a firearm or other similar offense
Yes
No
6
had an allegation of child abuse or neglect substantiated
Yes
No
7
had a minor removed from my/our care because of an allegation of child abuse or neglect
Yes
No
8
been awaiting trial or is on trial for any offense listed above
Yes
No
9
a criminal history that makes the home unsuitable
Yes
No
10
a current child abuse or neglect allegation pending.
Yes
No
§17a-145-160 Limitations to Number of Placements in One Foster Home
I/We will accept placements of children in my/our home in accordance with my/our license and as specified by regulations.
a.
More than three (3) foster or prospective adoptive children in the home
Yes
No
b.
A total of six (6) children, including the foster or prospective adoptive family’s natural and adopted children
Yes
No
c.
More than two (2) children under two (2) years of age
Yes
No
d.
More than three (3) children under six (6) years of age, except in the cases of siblings
Yes
No
e.
More than two (2) non-ambulatory children who are incapable of self-preservation
Yes
No
Page 4 of 4
Conn. Gen. Stat. §17a-28 and §17a-101k Confidentiality
. …”Records maintained by [DCF] shall be confidential and shall not be disclosed… Any unauthorized disclosure shall be punishable by a fine of not more than
one thousand dollars or imprisonment for not more than one year, or both."
"...The information contained in the Central Registry and any other information relative to child abuse, wherever located, shall be confidential…"
"...Any violation of this section or the regulations adopted by the commissioner under this section shall be punishable by a fine of not more than one thousand
dollars or imprisonment for not more than one year."
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-91 requires in part:
"HIPAA seeks to safeguard the privacy and security of health information (oral, written, or recorded in any form) that relates to either the physical or mental health
or condition of an individual; the provision of health care to an individual, or the payment for health care provided to an individual..."
"As a business associate, the licensed family resource must comply with all terms and conditions of the HIPAA provisions."
In accordance with the above statutes, I/we agree that I/we will not disclose confidential information, including health information, about
children under the care of DCF or their families which may come to my/our attention with anyone other than DCF staff unless authorized to
Yes
No
do so.
I/We also acknowledge that I/we have received a copy of the HIPAA provisions.
Yes
No
By signing below, I/we agree that I have been informed of my/our rights and responsibilities and DCF’s responsibilities pursuant to the
state and federal foster care statutes regulations and agree to abide by them.
Name of Parent 1
Signature of Parent 1
Date
Name of Parent 2
Signature of Parent 2
Date
Reviewed and Approved by:
Name of Social Worker
Signature of Social Worker
Date:
Name of Social Work Supervisor
Signature of of Social Work Supervisor
Date:
Name of Program Manager or Designee (if required):
Signature of Program Manager or Designee:
Date:
Page of 4