Form 06AC008E (DDS-8) "Specialized Foster Care/Agency Companion Services Application" - Oklahoma

What Is Form 06AC008E (DDS-8)?

This is a legal form that was released by the Oklahoma Department of Human Services - a government authority operating within Oklahoma. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 10, 2021;
  • The latest edition provided by the Oklahoma Department of Human Services;
  • 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 06AC008E (DDS-8) by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Human Services.

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Download Form 06AC008E (DDS-8) "Specialized Foster Care/Agency Companion Services Application" - Oklahoma

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Specialized Foster Care/
Agency Companion Services
Application
Foster Care application
Agency Companion Services application
Applicant Information
Identifying Information
Name (last, first,
middle initial) -
Tribal
Social
include any
member
security
aliases
affiliation
Birthdate
Race
Religion
number
Applicant
Spouse
Other Members of the Household
All persons (children, relatives, other members) living in the home must be included.
Name (last, first, middle
Social
initial) - include any
Grade or
security
aliases
Relationship
Birthdate
Sex
occupation
number
Military Service History
Branch of service
Service dates
Applicant
Spouse
Educational History
List highest grade completed or specify advanced degree.
High school
College
Name and location
Date
Applicant
Spouse
06AC008E
Page 1 of 6
9/10/2021
Specialized Foster Care/
Agency Companion Services
Application
Foster Care application
Agency Companion Services application
Applicant Information
Identifying Information
Name (last, first,
middle initial) -
Tribal
Social
include any
member
security
aliases
affiliation
Birthdate
Race
Religion
number
Applicant
Spouse
Other Members of the Household
All persons (children, relatives, other members) living in the home must be included.
Name (last, first, middle
Social
initial) - include any
Grade or
security
aliases
Relationship
Birthdate
Sex
occupation
number
Military Service History
Branch of service
Service dates
Applicant
Spouse
Educational History
List highest grade completed or specify advanced degree.
High school
College
Name and location
Date
Applicant
Spouse
06AC008E
Page 1 of 6
9/10/2021
Current Employment/Source of Income
Employer
Employer
Employer
Date
Monthly
Employer
address
Phone
email
employed
salary
Applicant
Spouse
Employment History
Provide 5 years employment history for primary contractor.
Employer
Employer
Dates
Monthly
Employer
Employer address
phone
email
employed
salary
Caregiver Experience
Yes
No
Have you ever cared for a child or an adult for any other agency or private
individual?
If yes, give name and address of agency or individual.
Mental Health History
Yes
No
Do you or any member of your household participate in any type of counseling,
therapy, or inpatient treatment?
When yes, provide the following information. If more than one provider was seen, list each provider
separately.
Beginning
Household
date of
Ending date
member name
Provider name Provider address Provider phone
treatment
of treatment
Legal History
Yes
No
Have you or any member of your family or household been arrested for or
convicted of a criminal action?
If yes, explain.
06AC008E
9/10/2021
Page 2 of 6
Yes
No
Are you or any member of your family or household currently on probation or
parole?
If yes, explain.
Yes
No
Have you or any member of your family or household been investigated for
physical abuse, sexual abuse, exploitation, or neglect of any child, adult, or
animal?
References
Give as references six persons (of whom not more than two are relatives) who are well acquainted
with your family. If a relative is listed, give relationship. Give local references, if possible.
Telephone
Relationship to
Name
Mailing address
number
Email address
applicant
Adult Children Not Living in the Home
Provide the contact information for all adult children not living in the home.
Telephone
Relationship to
Name
Mailing address
number
Email address
applicant
06AC008E
9/10/2021
Page 3 of 6
Signature
NOTICE: Oklahoma Human Services (OKDHS) has assured compliance with DHHS Regulations,
Title 45, Code of Federal Regulations Part 80 (which implements Public Law 88-352 Civil Rights Act
of 1964, Section 601), Part 84 (which implements Public Law 93-112, Rehabilitation Act of 1973,
Section 504), and Part 90 (which implements Public Law 94-135, Age Discrimination Act of 1975,
Section 301). These laws and regulations prohibit excluding from participation in, denying the
benefits of, or subjecting to discrimination under any program or activity receiving Federal Financial
Assistance any person on the grounds of race, color, or national origin or any qualified person on
the basis of age except as legislatively permitted or required. Written complaints of noncompliance
with any of these laws should be made to the Director of Human Services, P.O. Box 25352,
Oklahoma City, Oklahoma 73125, or the Secretary of Health and Human Services, Washington D.C.
or both.
We, the undersigned, declare this information is true and authorize DHS to use the above
information in completing an investigation of our application, including checking the National Crime
Information Center and Central Child Abuse Registry. We further understand that the placement of
an individual in our home will be on a temporary basis, supervised by a staff member of OKDHS,
and subject to removal at the discretion of OKDHS. Failure of all members of the household over
age 18 to sign, complete and provide correct information on this application will result in denial,
withdrawal, or cancellation of the application.
Applicant signature
Date
Spouse signature
Date
Other adult member of household signature
Date
Other adult member of household signature
Date
06AC008E
9/10/2021
Page 4 of 6
Items Required to be Submitted with the Completion of this Application
Check boxes to indicate evidence of completion is attached for each item:
Pre-Screening Process:
06AC013E, Pre-Screening for Specialized Foster Care/Agency Companion Services
04AD003E, Request for Background Check
04FT007E, Request to Release Child Abuse and Neglect Findings
JOLTS check through the Office of Juvenile Affairs
Fingerprints obtained through OKDHS
Pre-Screening Process:
06AC008E, Specialized Foster Care/Agency Companion Services Application
06AC010E, Medical Examination Report, or physician generated physical exam report
06AC003E, Foster Parent/Companion Family Reference Letter for Adult Children
06AC018E, Self-Study Questionnaire
06AC029E, Employer Reference Letter
06AC058E, Reference Letter, for each reference provided by the applicant (6 personal
references required for Agency Companion/SFC Parent)
06AC002E, Family Financial Assessment
06AC001E, Foster Parent/Companion Health History
Include copies of:
Utility references
Social Security card
Drivers license or state issued identification for all adult household members
Motor vehicle record
Home insurance
Vehicle insurance
Pet vaccinations
All divorce decrees, when applicable
Current marriage license, when applicable
Verification of lawful residence when not born in the United States, when applicable
Immunizations for children in the home
Water testing when the household water source is well water
Onboarding:
06MP050E, Notice of Responsibility Regarding Online Training
06AC069E, Review of Policies and Areas of Responsibilities
06AC020E, Evacuation/Escape Plan
06AC004E, DDS House Assessment
Training verification:
CPR/FA
MAT
Guiding Principles
06AC008E
9/10/2021
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