Form DCF-720 "Verification of Requirements for Approval/Re-approval for Foster & Prospective Adoptive Families" - Connecticut

What Is Form DCF-720?

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 March 24, 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-720 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

ADVERTISEMENT
ADVERTISEMENT

Download Form DCF-720 "Verification of Requirements for Approval/Re-approval for Foster & Prospective Adoptive Families" - Connecticut

1071 times
Rate (4.7 / 5) 64 votes
Connecticut Department of Children and Families
VERIFICATION OF REQUIREMENTS FOR APPROVAL/RE-APPROVAL FOR FOSTER & PROSPECTIVE ADOPTIVE FAMILIES
DCF-720
3/24/17 (Rev.)
Page 1 of 5
Parent 1
Parent 1
Middle:
Last Name:
First Name:
Primary
Race:
Ethnicity:
Select One
DOB:
SS#:
Select One
Select One
Language:
Marital
Home #:
Work #:
Gender:
U.S. Citizen?:
Yes
No
Select One
Select One
Status:
Parent 2
Parent 2
Middle:
Last Name:
First Name:
Primary
Race:
Ethnicity:
DOB:
Select One
SS#:
Select One
Select One
Language:
Marital
Home #:
Work #:
Gender:
U.S. Citizen?:
Yes
No
Select One
Select One
Status:
Address:
City/Town:
State:
Zip:
Initial Approval
Re-Approval
LINK PROVIDER #:
(required on all 720’s except initial):
Transfer-Closing Agency:
Kinship
Fictive Kin
Agency Name:
Initial Application Date:
Most Recent Approval Application Date:
Select appropriate level of Foster Care:
Select One
Pre-service Training BEGIN Date:
Approval/Re-Approval BEGIN Date
Pre-service Training END Date:
Approval/Re-Approval END Date
NOTE: ALL BACKGROUND CHECKS MUST BE WITHIN 60 DAYS PRIOR TO LICENSE DATE FOR ALL HOUSEHOLD MEMBERS AGE 16 AND OLDER
Date State and FBI
Date DMV Check
Date Child Protection
Date Local Police
Name of all Household Members
Date of Birth
Relationship
Livescan Received
Received
History Received
Check Received
Select One
Select One
Select One
Select One
Select One
Select One
Select One
NOTE: RE-APPROVAL REQUIRED FOR ALL HOUSEHOLD MEMBERS AGE 16 AND OLDER
Date DPS-846-C
Date DMV Check
Date Child Protection
Date Local Police
Name of all Household Members
Date of Birth
Relationship
Received
Received
History Received
Check Received
Select One
Select One
Select One
Select One
Select One
Select One
Select One
NOTE: Submitting this form as the LINK Registration certifies that none of the individual’s listed have criminal
and/or CPS histories that would preclude them from being approved as a foster/adoptive parent, per Connecticut Regulations
UPDATES / CHANGES
Effective Date:
Address / Phone # Change
Home Closed
Reason Home Closed (use code from list):
Add Background Checks (Name):
DOB:
Relationship:
Marital Status
Effective Date:
Select One
Select One
New Household Member (Name):
DOB:
Relationship:
Marital Status
Effective Date:
Select One
Select One
New Household Member (Name):
DOB:
Relationship:
Marital Status
Effective Date:
Select One
Select One
Deactivate Household Member Name:
Effective Date:
Deactivate Household Member Name:
Effective Date:
Agency Contact Person Name:
Phone #:
E-mail:
Date:
Connecticut Department of Children and Families
VERIFICATION OF REQUIREMENTS FOR APPROVAL/RE-APPROVAL FOR FOSTER & PROSPECTIVE ADOPTIVE FAMILIES
DCF-720
3/24/17 (Rev.)
Page 1 of 5
Parent 1
Parent 1
Middle:
Last Name:
First Name:
Primary
Race:
Ethnicity:
Select One
DOB:
SS#:
Select One
Select One
Language:
Marital
Home #:
Work #:
Gender:
U.S. Citizen?:
Yes
No
Select One
Select One
Status:
Parent 2
Parent 2
Middle:
Last Name:
First Name:
Primary
Race:
Ethnicity:
DOB:
Select One
SS#:
Select One
Select One
Language:
Marital
Home #:
Work #:
Gender:
U.S. Citizen?:
Yes
No
Select One
Select One
Status:
Address:
City/Town:
State:
Zip:
Initial Approval
Re-Approval
LINK PROVIDER #:
(required on all 720’s except initial):
Transfer-Closing Agency:
Kinship
Fictive Kin
Agency Name:
Initial Application Date:
Most Recent Approval Application Date:
Select appropriate level of Foster Care:
Select One
Pre-service Training BEGIN Date:
Approval/Re-Approval BEGIN Date
Pre-service Training END Date:
Approval/Re-Approval END Date
NOTE: ALL BACKGROUND CHECKS MUST BE WITHIN 60 DAYS PRIOR TO LICENSE DATE FOR ALL HOUSEHOLD MEMBERS AGE 16 AND OLDER
Date State and FBI
Date DMV Check
Date Child Protection
Date Local Police
Name of all Household Members
Date of Birth
Relationship
Livescan Received
Received
History Received
Check Received
Select One
Select One
Select One
Select One
Select One
Select One
Select One
NOTE: RE-APPROVAL REQUIRED FOR ALL HOUSEHOLD MEMBERS AGE 16 AND OLDER
Date DPS-846-C
Date DMV Check
Date Child Protection
Date Local Police
Name of all Household Members
Date of Birth
Relationship
Received
Received
History Received
Check Received
Select One
Select One
Select One
Select One
Select One
Select One
Select One
NOTE: Submitting this form as the LINK Registration certifies that none of the individual’s listed have criminal
and/or CPS histories that would preclude them from being approved as a foster/adoptive parent, per Connecticut Regulations
UPDATES / CHANGES
Effective Date:
Address / Phone # Change
Home Closed
Reason Home Closed (use code from list):
Add Background Checks (Name):
DOB:
Relationship:
Marital Status
Effective Date:
Select One
Select One
New Household Member (Name):
DOB:
Relationship:
Marital Status
Effective Date:
Select One
Select One
New Household Member (Name):
DOB:
Relationship:
Marital Status
Effective Date:
Select One
Select One
Deactivate Household Member Name:
Effective Date:
Deactivate Household Member Name:
Effective Date:
Agency Contact Person Name:
Phone #:
E-mail:
Date:
Page 2 of 5
Is the following documentation contained in the Applicant’s Approved Parent’s Record?
NOTE: “*” indicates items that are to be obtained again at re-approval. “**” are items for re-approval (if appropriate)
Application
Yes
No
Protective Service Check *
Yes
No
Local Police Name And Address Search *
Yes
No
Criminal History Record (DPS-846-C) *
Yes
No
State Police Fingerprint Results
Yes
No
FBI Fingerprint Results
Yes
No
Department of Motor Vehicles Check
Yes
No
Marriage / Legal Separation / Divorce (Adoption)
Yes
No
N/A
Physician’s Statement for Foster Care or Adoption Applicant **
Yes
No
Confidentiality Agreement
Yes
No
Disciplinary Agreement
Yes
No
Financial Statement and Verifying Documentation
Yes
No
Authorization for a Placement which exceeds population limitations
Yes
No
Lead Paint Test Results **
Yes
No
N/A
Well Water Test Results **
Yes
No
N/A
Pool Inspection **
Yes
No
N/A
Auxiliary Heating Systems **
Yes
No
N/A
Pet Vaccinations Certificate
Yes
No
N/A
References Received (At Least 3)
Yes
No
Completed Family Assessment
Yes
No
Adoption Update
Yes
No
N/A
Family Registration – Adoption (DCF-334)
Yes
No
N/A
Was the Applicant or Approved Parent(s):
Given a copy of regulations 17a-145-130 through 17a-145-160?
Yes
No
Informed of his/her/their responsibilities indicated in the regulations?
Yes
No
Informed of his/her/their responsibilities to remain in compliance with these regulations?
Yes
No
§17a-145-160
Has it been explained to the applicant/approved parent by the child placing agency that State Regulation 17a-145-160 requires that, except with authorization by
the Commissioner, children shall not be placed in a foster or prospective adoptive family if that placement shall result in:
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
§17a-150-90
Was an assessment completed for each applicant/approved parent and all members of the household to determine the ability of the
Yes
No
applicant/approved parent to comply with the regulations of Connecticut state agencies §§17a-150-90 through 17a-150-114
§17a-150-95 physical requirements of applicants’ / approved parent(s)’ homes
1.
Are dwellings and furnishings clean, comfortable and in good repair?
Yes
No
2.
Is the home reasonably safe from fire?
Yes
No
3.
Are the home and grounds reasonably free from anything that constitutes a hazard to children?
Yes
No
4.
Was peeling indoor or outdoor paint accessible to children determined to be non-toxic?
Yes
No
N/A
5.
Is equipment used by the children free from paint or other covering material which is poisonous?
Yes
No
6.
Do all swimming pools comply with local and state regulations?
Yes
No
N/A
7.
Are medicines and toxic and flammable materials kept out of the reach of children?
Yes
No
8.
Is there 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.
Do all heating systems comply with state and local building and fire codes?
Yes
No
10. Are there adequate sewage and garbage facilities?
Yes
No
11. Is all power driven machinery or other hazardous equipment properly safeguarded and is/will their use by any foster or adoptive
Yes
No
child (be) properly supervised by an adult?
12. Are emergency evacuation plans established?
Yes
No
13. Is a furnace enclosed if it is located on the same floor as a living space?
Yes
No
N/A
14. Are smoke detectors in operating condition and located so as to protect sleep areas, play areas and the basement?
Yes
No
N/A
§17a-150-96: Telephone
1.
Is there a working telephone with emergency numbers posted in an easily visible location?
Yes
No
2.
Does the applicant/approved parent agree to notify the agency within one (1) business day of any change in the telephone number
Yes
No
or telephone status?
Page 3 of 5
§17a-150-97: children’s bedroom, clothing and privacy
Is each bedroom enclosed on all sides, with a window and a door that leads into a hallway or other common area?
1.
Yes
No
2.
Does each bedroom have at least two (2) approved means of exit capable of providing for escape in the event of fire or disaster?
Yes
No
3.
Will/are bedrooms for children be used for sleeping purposes and customary children’s activities only, and NOT used for general
Yes
No
purposes of other members of the family?
4.
Will/do foster and adoptive children under three (3) years of age sleep on the same floor and in close proximity to foster or adoptive
Yes
No
parents or a responsible adult?
5.
Will/is a separate bed be provided for each child except that siblings of the same sex may sleep together in a double-sized or larger
Yes
No
bed with the approval of the chief administrative officer of the child placing agency?
Does the applicant/approved parent agree that:
6.
a.
No child three (3) years of age or older shall be permitted to share a bedroom with another child of the opposite sex
Yes
No
N/A
or a same sex child of disparate age.
b.
No child over one (1) year of age shall share a room with an adult without the permission of the chief
Yes
No
N/A
administrative officer of the child placing agency.
c.
No more than four (4) children including the applicant/approved family’s own children shall sleep in the same
Yes
No
N/A
room without the permission of the Chief Administrative Officer of the child placing agency:
7.
Will/is children’s clothing be kept clean and in good condition in keeping with the standards of the community?
Yes
No
8.
Will/is there be safe storage for children’s clothing and personal possessions?
Yes
No
9.
Will/is each child be afforded privacy appropriate to his/her growth and development?
Yes
No
§17a-150-98: food and water
1.
Does all food for human consumption, food storage and preparation, personal cleanliness and general care of the home meet
Yes
No
generally accepted health standards?
2.
Does the applicant/approved parent agree that non-pasteurized milk products will NOT be provided to any child in care, or without
Yes
No
the approval or knowledge of the foster or adoptive family
3.
Is the water supply safe and adequate to meet the needs of the household?
Yes
No
§17a-150-99: firearms and weapons
Does the applicant/approved parent or any resident in the home possess a firearm or other type of dangerous weapon?
Yes
No
If Yes, does the applicant/approved parent ensure that:
a.
Firearms and ammunition are locked in separate places inaccessible to all children
Yes
No
b.
Whenever practicable, firearms are equipped with a trigger guard lock
Yes
No
c.
Other types of dangerous weapons are unstrung or unloaded and stored in locked containers out of the reach of children
Yes
No
d.
Keys to the locked storage area of firearms, other types of dangerous weapons, trigger guards, and ammunition are kept in the
Yes
No
secure possession of an adult or reasonably secure from children
§17a-150-100: animals
Are all animals kept in a safe and sanitary manner in compliance with all statutes and regulations regarding vaccination and generally
Yes
No
accepted veterinary care?
17a-150-101: health standards for applicants/approved parents and members of the household
1.
Has each person living in the home, as evidenced by a written statement by a physician based upon a physical examination within the
Yes
No
previous 12 months:
Been determined to be in good health or are specified members of the family receiving all necessary continuing medical care?
No
a.
Yes
b. Been determined to be free of communicable disease
Yes
No
c. Been determined to be physically and mentally able to provide care to children?
Yes
No
2.
Does the applicant/approved parent(s) agree to Notify the child placing agency whenever they or a member of the family contract a
Yes
No
communicable disease or if they develop a physical or mental infirmity which interferes with their child-caring ability?
3
Has the applicant suffered the death of a biological, adoptable or adopted child within one year of the application?
Yes
No
§17a-150-102: character standards of applicants/approved parents and other members of the household
Is the applicant/approved parent and other members of the household of good character, habits and reputation?
Yes
No
§17a-150-103: change in family conditions
Does the applicant/approved parent agree to notify the child placing agency, in writing, prior to, or not later than, one (1) business day
following, any change in circumstance or member of the household which would alter the statement of fact made in the application for
Yes
No
approval or which would effect the ability of the applicant or approved parent to provide ongoing care of the child?
§17a-150-104: reporting of the injury, illness, death, fire or absence of a child from placement
Does the applicant/approved parent agree to Notify the child placing agency, by telephone, within six (6) hours of any serious injury, serious
Yes
No
illness or death of a child, any fire in the home or any unauthorized absence of a child?
§17a-150-105: financial condition of the applicant/approved parent
1.
Does the applicant/approved parent have an income sufficient to meet the needs of their family?
Yes
No
2.
Does the applicant/approved parent agree that money received on behalf of the child shall be expended for the care of the
Yes
No
child?
§17a-150-106: substitute child care
Does the applicant/approved parent agree that if all adults in the home are employed or otherwise occupied for a substantial amount of
time away from the home, the care and supervision of the child must be provided by a competent individual and that the plans for such
Yes
No
care must be approved in advance by the chief administrative officer of the child placing agency?
Page 4 of 5
§17a-150-107: cooperation with the child’s treatment plan\
1.
Will/does the applicant/approved parent comply with the treatment plan for the child and work cooperatively with the department in all
Yes
No
matters pertaining to the child’s welfare?
2.
Will/does the applicant/approved parent accept, cooperate with and support arrangements made for the child to have contact, including
visits & correspondence, with the child’s biological family in keeping with the frequency indicated by the treatment plan; and agree that
Yes
No
visits will take place at the foster home or other location if deemed to be in the best interest of the child and foster family?
3.
Will/does the applicant/approved parent agree to be an active participant in reunification of the child with the child’s biological family if
Yes
No
so directed by DCF and the child placing agency?
§17a-150-108: limitation on the number of approvals or licenses allowed
Does the applicant/approved parent agree
To possess only one (1) approval or license for any form of out-of-home care
Yes
No
a.
b.
Not to hold dual approval
Yes
No
c.
Not to accept another child for placement on a private basis?
Yes
No
17a-150-109: general requirements of foster and prospective adoptive parents
1.
Is the applicant/approved parent physically, intellectually and emotionally capable of providing care, guidance and supervision of the child, including:
a.
Ensuring routine medical care, scheduling and transportation
Yes
No
b.
Obtaining and following instructions from the child’s medical provider for administering medication or treatment
Yes
No
c.
Keeping all medications clearly labeled and out of the reach of children
Yes
No
d.
Establishing plans to respond to illness and emergencies, including serious injuries and the ingestion of poison, with
Yes
No
appropriate first aid supplies available in the home, out of reach of the children
e.
Maintaining all documentation as required by the department
Yes
No
f.
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
Yes
No
appropriate to the age of the child in care
Promoting the social, intellectual, emotional, and physical development of each child by providing activities that meet these needs
g.
Yes
No
or any special needs
h.
Assuring adequate opportunity for cultural and educational activities in the family and in the community
Yes
No
i.
Providing children who do Not share the same language as the caretaker with opportunities to practice their native language
Yes
No
as they become bi-lingual or multi-lingual
j.
Providing adequate opportunity for religious training and participation appropriate to the child’s religious denomination and
Yes
No
wishes, NOT the provider or caregiver’s preferred religion or faith
k.
Not requiring any child to participate in religious practices contrary to the child’s beliefs and faith, and not forcing any child to
Yes
No
attend religious services, ceremonies or faith-based events if they don’t wish to
l.
Providing emotional support and an environment that meets the child’s ethnic and cultural needs
Yes
No
m.
Assuring the child’s participation in an approved education program, including regular school attendance
Yes
No
n.
Cooperating with proper authorities regarding the child’s educational needs
Yes
No
o.
Guiding the child in the acquisition of daily living skills, including the assigning of daily chores to the child on the basis of the
Yes
No
child’s abilities and developmental level
p.
Providing infants and toddlers with ample opportunity for freedom of movement each day outside of a crib or playpen
Yes
No
q.
Holding infants for all bottle feedings, as well as at other times, for attention and verbal communication?
Yes
No
2.
Does the applicant/approved parent agree that they and members of the household, substitute care providers and other persons having regular access to
children in the home shall
a.
Give the child humane and affectionate care
Yes
No
b.
Be a positive role model to the child and instruct the child in appropriate behavior
Yes
No
c.
Establish limits and assist the child to develop self-control and judgment skills
Yes
No
d.
Encourage the children to assume age-appropriate responsibility for their decisions and actions?
Yes
No
3.
Does the applicant/approved parent agree to:
a.
Use disciplinary methods appropriate to the child’s age and level of development
Yes
No
b.
Not use physically or verbally abusive, neglectful, humiliating, frightening or corporal punishment, including but Not limited to
Yes
No
spanking, cursing or threats
c.
Obtain prior written approval from the commissioner or designee when unusual circumstances require continued or frequent
Yes
No
use of physical or mechanical restraints
d.
Complete all assessment and training requirements as prescribed by the DCF and the child placing agency
Yes
No
§17a-150-110: foster family or prospective adoptive family criminal history; pending criminal actions; history of child abuse or neglect
1. Has the applicant or any member of the household: (Note: a “Yes” may disqualify the applicant):
a.
Been convicted of injury or risk of injury to a Minor or other similar offenses against a Minor
Yes
No
Been convicted of impairing the morals of a Minor or other similar offenses against a Minor
b.
Yes
No
c.
Been convicted of violent crime against a person or other similar offenses
Yes
No
d.
Been convicted of the possession, use, or sale of controlled substances within the past five (5) years
Yes
No
e.
Been convicted of illegal use of a firearm or other similar offenses
Yes
No
f.
Have a child protection history check that reveals a substantiation of abuse or neglect
Yes
No
g.
Had a Minor removed from their care because of child abuse or neglect
Yes
No
Page 5 of 5
2. Has the approved parent or any member of the household: (Note: a “Yes” may disqualify the applicant):
a.
Been convicted of injury or risk of injury to a Minor or other similar offenses against a Minor
Yes
No
Been convicted of impairing the morals of a Minor or other similar offenses against a Minor
b.
Yes
No
c.
Been convicted of violent crime against a person or other similar offenses
Yes
No
d.
Been convicted of the possession, use, or sale of controlled substances within the past five (5) years
Yes
No
e.
Been convicted of illegal use of a firearm or other similar offenses
Yes
No
f.
Have a child protection history check that reveals a substantiation of abuse or neglect
Yes
No
g.
Had a Minor removed from their care because of child abuse or neglect
Yes
No
3. Is / Has the applicant/approved parent or any member of the household (Note: a “Yes” may disqualify the applicant ):
a.
Awaiting trial, or on trial, for charges as described above in 1. a-e
Yes
No
b.
A criminal record that makes the home unsuitable
Yes
No
c.
A current child abuse or neglect allegation pending?
Yes
No
§17a-150-111
Does the applicant/approved parent agree to accept placements of children in their home in accordance with their approval and as
Yes
No
specified by regulations 17a-145-130 through 17a-145-160?
§17a-150-156
Has it been explained to the applicant/approved parent by the child placing agency that they may request a review, hearing or other
method of appeal as shall be provided by the child placing agency seeking any type of administrative hold, suspension, revocation or
Yes
No
refusal to renew an approval?
§17a-150-160:
Has it been explained to the applicant/approved parent by the child placing agency that State Regulation 17a-145-160 requires that, except with authorization by the
commissioner, children shall Not be placed in a foster or prospective adoptive family if that placement shall result in:
a.
more than three foster or prospective adoptive children in the home
Yes
No
b.
total of six (6) children including the foster or prospective adoptive family’s natural and adoptive children
Yes
No
c.
more than two children under two years of age
Yes
No
d.
more than three children under six years of age, except in the case of siblings
Yes
No
e.
more than two (2) Non-ambulatory children who are incapable of self-preservation
Yes
No
RECOMMENDATION FOR APPROVAL
Approval Status:
Regular
Waiver
Approval Type:
Foster Care
Adoption
Number of Children:
Race:
Gender:
Female
Male
Either
Age Range:
Select One
Submitted by:
Date:
Approved by:
Date:
Approved by:
Date:
REQUEST FOR A WAIVER (Applies to any type of license/approval)
A waiver may be granted by the Commissioner or designee in accordance with the requirements of the Regulations of Connecticut State Agencies §17a-145-159.
Specify the area(s) of substantial compliance or Non-compliance and, if required, the alternative plan to achieve compliance:
Approved by:
Date: