Form DCF-008 "Emergency Home Assessment for Child-Specific Placement" - Connecticut

What Is Form DCF-008?

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 November 1, 2018;
  • 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-008 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-008 "Emergency Home Assessment for Child-Specific Placement" - Connecticut

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Connecticut Department of Children and Families
EMERGENCY HOME ASSESSMENT FOR CHILD-SPECIFIC PLACEMENT
DCF-008
11/18 (Rev.)
Note: For use when a relative or fictive kin caregiver is not yet licensed or approved pursuant to Conn. Gen. Stat. §17a-114(c).
Page 1 of 5
Name(s) of Child(ren) to be placed:
DOB
LINK Case #:
First Time Placed?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Prospective Foster Parent #1
Prospective Foster Parent #2
Birth Name:
Birth Name:
Previous Married Names (if applicable):
Previous Married Names (if applicable):
AKA (if applicable):
AKA (if applicable):
DOB:
Home Phone:
DOB:
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-mail:
Current Address: (No. and Street):
City:
State:
Zip:
REQUIRED Checks:
Check Completed?:
REQUIRED Checks:
Check Completed?:
Protective Services History Checks
Yes
Attached
Pending
Protective Services History Checks:
Yes
Attached
Pending
LINK Case Search
LINK Case Search
LINK CMS Search
LINK CMS Search
LINK Perpetrator Search
LINK Perpetrator Search
LINK Person Search
LINK Person Search
LINK Provider Search
LINK Provider Search
Criminal History Checks:
Criminal History Checks:
COLLECT
COLLECT
DMV
DMV
DPH (if applicable)
DPH (if applicable)
Fingerprints
Fingerprints
Judicial (Pending Arrests, if applicable)
Judicial (Pending Arrests, if applicable)
Local Police (if applicable)
Local Police (if applicable)
Sex Offender
Sex Offender
State Police
State Police
Connecticut Department of Children and Families
EMERGENCY HOME ASSESSMENT FOR CHILD-SPECIFIC PLACEMENT
DCF-008
11/18 (Rev.)
Note: For use when a relative or fictive kin caregiver is not yet licensed or approved pursuant to Conn. Gen. Stat. §17a-114(c).
Page 1 of 5
Name(s) of Child(ren) to be placed:
DOB
LINK Case #:
First Time Placed?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Prospective Foster Parent #1
Prospective Foster Parent #2
Birth Name:
Birth Name:
Previous Married Names (if applicable):
Previous Married Names (if applicable):
AKA (if applicable):
AKA (if applicable):
DOB:
Home Phone:
DOB:
Home Phone:
Work Phone:
Cell Phone:
Work Phone:
Cell Phone:
E-mail:
E-mail:
Current Address: (No. and Street):
City:
State:
Zip:
REQUIRED Checks:
Check Completed?:
REQUIRED Checks:
Check Completed?:
Protective Services History Checks
Yes
Attached
Pending
Protective Services History Checks:
Yes
Attached
Pending
LINK Case Search
LINK Case Search
LINK CMS Search
LINK CMS Search
LINK Perpetrator Search
LINK Perpetrator Search
LINK Person Search
LINK Person Search
LINK Provider Search
LINK Provider Search
Criminal History Checks:
Criminal History Checks:
COLLECT
COLLECT
DMV
DMV
DPH (if applicable)
DPH (if applicable)
Fingerprints
Fingerprints
Judicial (Pending Arrests, if applicable)
Judicial (Pending Arrests, if applicable)
Local Police (if applicable)
Local Police (if applicable)
Sex Offender
Sex Offender
State Police
State Police
Page 2 of 5
Household Member(s) Name(s):
DOB:
Social Security #
Relationship To Applicant
(e.g., children, other relatives, significant others, babysitters)
Select One
Select One
Select One
Select One
Select One
Frequent Visitors To The Home:
DOB:
Social Security #
Relationship To Applicant
(e.g., children, other relatives, significant others, babysitters)
Select One
Select One
Select One
Select One
Select One
Home will require immediate daycare if child(ren) is (are) placed:
Yes
No
BASIC ASSESSMENT OF HOME (See Regulations for further explanation of each category)
1
Dwelling and furnishings are reasonably clean, comfortable and in good repair.
Yes
No
2
Dwelling is reasonably determined to be safe from fire and has working smoke detectors.
Yes
No
3
The home and grounds are reasonably free from anything that would constitute a hazard to children.
Yes
No
There is sufficient indoor and outdoor space, ventilation, toilet facilities, light and heat to ensure the health and comfort of all
4
Yes
No
members of the household.
5
Sleeping arrangements:
a.
The bedroom for the child(ren) is enclosed on all sides, has a window that opens and a door that leads into a
Yes
No
hallway or other common living area.
b.
Each child will have his or her own bed.
Yes
No
c.
If sharing a bedroom, each child will share a room with children of the same sex.
Yes
No
d.
If sharing a bedroom, each child will share a room with children of the same age.
Yes
No
e.
If child is under five years old, he or she will sleep on same floor as foster parent.
Yes
No
6
The home has a pool.
Yes
No
7
The home has a working telephone.
Yes
No
8
The home has well water.
Yes
No
9
Sewage and garbage facilities are adequately maintained.
Yes
No
10
Firearms or other types of dangerous weapons are secured.
Yes
No
11
Pets are safely supervised; vaccinations and licenses for cats and dogs are current.
Yes
No
12
Finances are sufficient to meet the needs of the family.
Yes
No
13
There is peeling paint inside or outside.
Yes
No
Page 3 of 5
Comments or any other concerns noted with the family including mental health concerns, medications, hospitalizations, therapy or medical restrictions for a
household member and the condition of home. Please explain, be brief and succinct:
If you need additional space, please use the next page:
Page 4 of 5
…continued from previous section:
Page 5 of 5
Based on the information submitted and the results of a home inspection, this home:
Meets
Does NOT Meet
Minimum licensing requirements. (NOTE: This DOES NOT constitute approval of licensing.)
Date of proposed or actual placement:
A WAIVER is necessary for the following regulatory concerns in order to authorize placement.
(NOTE: A DCF-001, “Request for Waiver of Foster Home Licensing Regulation(s),” MUST be completed and attached.]
TYPE of Waiver Needed
DCF Approval Needed
Check if Applicable
Physical requirements of the home (egress, pools, lead paint for children less than six years old)
CPS and FASU Program Manager
Telephone
CPS and FASU Program Manager
Children's bedroom, clothing and privacy
CPS and FASU Program Manager
In-home daycare
CPS and FASU Program Manager
Financial condition
CPS and FASU Program Manager
Food and water
CPS and FASU Program Manager
Animals
CPS and FASU Program Manager
Health standards
CPS and FASU Program Manager
Simultaneous licensing by the DDS (Developmental Services) or another child placing agency
OChYP Director
Criminal history and pending criminal cases
DCF Commissioner
Substantiated child protective services history or pending CPS cases
DCF Commissioner
Over-capacity
Regional Administrator (RA)
More than one therapeutic foster care placement
RA & notification to OChYP Director
Authorization for waiver is hereby:
GRANTED
DENIED
Name of SW who conducted the “walk-through”:
Signature of SW (if applicable):
Date:
Name of FASU SWS (if applicable):
Signature of FASU SWS (if applicable):
Date:
Name of FASU PM (or Designee):
Signature of FASU PM (or Designee):
Date:
Page of 5