EMPLOYEE REQUEST FOR ADOPTION AND FOSTER CARE
The statewide Employee Foster Care and Adoption policy requires completion of this
form to ensure conflict of interest and ethical issues are addressed in cases where an
employee requests to foster or adopt a child in Nevada child welfare custody.
Name:
Date:
Position:
Phone:
Office:
Supervisor:
I am requesting approval to proceed with the homestudy/licensure process for the purpose
of:
providing foster care
adopting a special needs child
providing flexible family resource care
providing contract residential care
Specific child(ren) identified:
yes
no
If yes: This child(ren) has not been on my caseload nor have I had any professional
involvement as an employee with this child(ren) during the last three years.
I understand that this approval would not imply an approval as a foster or adoptive parent
or approval of the placement of any specific child(ren).
I have discussed my intention and reviewed the employee foster and adoption policy
packet with my supervisor. The packet included the policy, this request form and the
placement request form.
Employee Signature
Date
Recommend to Proceed: Approved
Denied
If Denied, please explain: __________________________________________________
________________________________________________________________________
________________________________________________________________________
Program Manager
Date
Recommend to Proceed: Approved
Denied
Deputy Administrator
Date
Recommend to Proceed: Approved
Denied
Administrator or Designee
Date
FPO 1009A Form
2012
EMPLOYEE REQUEST FOR ADOPTION AND FOSTER CARE
The statewide Employee Foster Care and Adoption policy requires completion of this
form to ensure conflict of interest and ethical issues are addressed in cases where an
employee requests to foster or adopt a child in Nevada child welfare custody.
Name:
Date:
Position:
Phone:
Office:
Supervisor:
I am requesting approval to proceed with the homestudy/licensure process for the purpose
of:
providing foster care
adopting a special needs child
providing flexible family resource care
providing contract residential care
Specific child(ren) identified:
yes
no
If yes: This child(ren) has not been on my caseload nor have I had any professional
involvement as an employee with this child(ren) during the last three years.
I understand that this approval would not imply an approval as a foster or adoptive parent
or approval of the placement of any specific child(ren).
I have discussed my intention and reviewed the employee foster and adoption policy
packet with my supervisor. The packet included the policy, this request form and the
placement request form.
Employee Signature
Date
Recommend to Proceed: Approved
Denied
If Denied, please explain: __________________________________________________
________________________________________________________________________
________________________________________________________________________
Program Manager
Date
Recommend to Proceed: Approved
Denied
Deputy Administrator
Date
Recommend to Proceed: Approved
Denied
Administrator or Designee
Date
FPO 1009A Form
2012
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