Form CFS 542 Initial Inquiry - Illinois

Form CFS542 is a Illinois Department of Children and Family Services form also known as the "Initial Inquiry". The latest edition of the form was released in February 1, 2018 and is available for digital filing.

Download a PDF version of the Form CFS542 down below or find it on Illinois Department of Children and Family Services Forms website.

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CFS 542
State of Illinois
Rev 2/2018
Department of Children and Family Services
INITIAL INQUIRY
DATE of Referral
Date entered into Sharepoint
Date inquiry closed
Circle one:
Traditional
Relative
Child Specific
ICPC
SSN
Name(s) of Potential Applicant(s)
Email Address:
Date of Birth
Last 4 Digits
A.
B.
ZIP Code
Home Address
City
Primary Phone Numbers
H:
C:
SSN
SSN-
Name(s) of Other Adults (18 and Older) Living in the Home
DOB
Name(s) of Other Adults (18 and Older) Living in the Home
DOB
Last 4 #s
Last 4 #s
1.
3.
2.
4.
Name, Gender, and Age of Any Child under 18 Living in the Home:
1.
/
/
2.
/
/
3.
/
/
4.
/
/
5.
/
/
6.
/
/
Quality of Care Concerns Applicant
Has the inquirer or any person living in the household
In the Last 5 Years
Over 5 Years
:
Had a license revoked or refused to renew
Y
N
If yes, inform inquirer
If yes
Surrendered a license for cause
of statute language that
1) inform inquirer of the
Y
N
prevents them from
criteria or criterion that
Had an expired or surrendered license while either an abuse or neglect investigation or licensing
Y
N
applying at this time
identifies the individual as a
investigation was pending or an involuntary hold was placed on the home.
Quality of Care Concerns
Been the subject of allegations of abuse or neglect
If yes
Applicant
1) inform inquirer of the criteria or
Had an indicated report of abuse or neglect
2) explain the application
criterion that identifies the individual
Been the subject of licensing violation related to child health, safety and well-being that led to an
process
as a Quality of Care Concerns
involuntary hold.
3) send the inquirer a
Applicant
Been involved in one or more substantiated licensing complaints which were not corrected and
Preliminary Application
2) explain the application process
resulted in enforcement action.
3) send the inquirer a Preliminary
Application
1
Are you 21 years old or older? Yes
No
2
What is your Marital Status? Single
Married
Divorced
Widowed
3
Do you have proof of a marriage or civil union? Yes
No
(reference 402.12 (a)
4
Are you employed outside of the home? Yes
No
What is your source of income?
CFS 542
State of Illinois
Rev 2/2018
Department of Children and Family Services
INITIAL INQUIRY
DATE of Referral
Date entered into Sharepoint
Date inquiry closed
Circle one:
Traditional
Relative
Child Specific
ICPC
SSN
Name(s) of Potential Applicant(s)
Email Address:
Date of Birth
Last 4 Digits
A.
B.
ZIP Code
Home Address
City
Primary Phone Numbers
H:
C:
SSN
SSN-
Name(s) of Other Adults (18 and Older) Living in the Home
DOB
Name(s) of Other Adults (18 and Older) Living in the Home
DOB
Last 4 #s
Last 4 #s
1.
3.
2.
4.
Name, Gender, and Age of Any Child under 18 Living in the Home:
1.
/
/
2.
/
/
3.
/
/
4.
/
/
5.
/
/
6.
/
/
Quality of Care Concerns Applicant
Has the inquirer or any person living in the household
In the Last 5 Years
Over 5 Years
:
Had a license revoked or refused to renew
Y
N
If yes, inform inquirer
If yes
Surrendered a license for cause
of statute language that
1) inform inquirer of the
Y
N
prevents them from
criteria or criterion that
Had an expired or surrendered license while either an abuse or neglect investigation or licensing
Y
N
applying at this time
identifies the individual as a
investigation was pending or an involuntary hold was placed on the home.
Quality of Care Concerns
Been the subject of allegations of abuse or neglect
If yes
Applicant
1) inform inquirer of the criteria or
Had an indicated report of abuse or neglect
2) explain the application
criterion that identifies the individual
Been the subject of licensing violation related to child health, safety and well-being that led to an
process
as a Quality of Care Concerns
involuntary hold.
3) send the inquirer a
Applicant
Been involved in one or more substantiated licensing complaints which were not corrected and
Preliminary Application
2) explain the application process
resulted in enforcement action.
3) send the inquirer a Preliminary
Application
1
Are you 21 years old or older? Yes
No
2
What is your Marital Status? Single
Married
Divorced
Widowed
3
Do you have proof of a marriage or civil union? Yes
No
(reference 402.12 (a)
4
Are you employed outside of the home? Yes
No
What is your source of income?
State of Illinois
Department of Children and Family Services
Employer
Position
Full/Part
Hours
Years
5. Do you or your spouse work for DCFS or through a personal service contract or subcontract with the Department? Yes
No
If yes refer to POS and 402.4(b)
6
Do you rent or own your home? Rent
Own
7
Do you plan to remain in this home? Yes
No
8
Do you have adequate bedroom space and beds? Number of Bedrooms Available for Fostering: ____ Number of Beds Available for Fostering:___
9
Do you have a swimming pool? Yes
No
If yes, refer to 402.8(d). Your pool must be in compliance with the rule in order to become a foster parent.
10. Do you own any firearms? Yes
No
11 Have you or any household member been convicted of a crime other than a minor traffic violation (in accordance with Rules 385)? Yes
No
12 Are you able to provide the birthdates and social security numbers of all members in your household upon applying for a license. Yes
No
13 How many children under the age of 18 currently reside in your home, including children that visit frequently as part of a parent-child visitation?
14 Are you trying to become a foster parent for a particular child that is involved with another agency? Yes
No
15 Are you interested in becoming a foster parent for a child located in another state? Yes
No
16 Are both applicants willing and able to meet the pre-service training requirement? Yes
No
17 Are you able to provide names and full addresses for character references who know how you care for children? Yes
No
18 Language: Speaks language(s) other than English? No
Yes
If yes indicate Language:
Proficiency: Bilingual
Fluent
Conversational
19 Are you interested in adopting only? Yes
No
20 Would you be able to support the religious beliefs of children who do not share the same religious faith as you? Yes
No
21 Do you practice any faith/religion? Yes
No
Discussed the Following: Application Packet
: ____________________Background Checks
:__________________________Fingerprinting
_____________________
Medicals/Health /TB tests
:_____________Source of Income
:___________________Pets
(if any, please describe):__________________________________________
Motivation for Fostering/Adoption:______________________________________________________________________________________________________________
Special Needs/Sibling Groups/Teens/Age/Gender Preference?
State of Illinois
Department of Children and Family Services
Information Resulted In:
Returned Call:
Date/Time
Person Completing/ Source of Inquiry
Date/Time
Appointment Scheduled:
Date/Time
Referred to Private Agency
Assigned to:
Information Only
Caller will Call Back if Interested
Foster Care Licensing Representative
Date
Counseled Out
Use back for Additional Notes, PRIDE Referral Information, Final Status and/or Justification if Counseled Out.
Additional Notes:
Application Received: Y or N (If yes, the date application opened)____________________
SACWIS Check Applicant A – Date: _______________ Finding: _____________________
SACWIS Check Applicant B – Date: _______________ Finding: _____________________
Referred to PRIDE – Date: _______________ Location: _____________________
Final Status of Application: ____________________________________________________
Justification for Counseling Out the Family (Licensing Issues, Other Reasons), when applicable:
FDS Signature:____________________________________________________ Date: __________________________
Supervisor Signature:_______________________________________________ Date: __________________________
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