Updated: 12/9/22 OMB 0970-0564 [valid through MM/DD/2026]
Foster Home Monitoring Checklist – Walkthrough (LTFC and TFC) – Unlicensed Facility (UF) Quarterly Health and Safety Visit1
General Home Information |
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Foster Parent Name(s):
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Name of UC: |
Foster Home Licensed Capacity: |
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Foster Home Address:
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Date of Home Visit: |
# of Children in Foster Home: |
Age/Gender: |
Program Name:
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Type of Foster Home License: |
# of Adults in Foster Home: |
Relationship to FP/Gender: |
*** PLEASE NOTE ANY NEW/UNKNOWN NAMES, AGES, RELATIONSHIPS, and MEDICAL NEEDS of Adults or Children living or working in the home (verify all info with FP case file)***
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Cleaning chemicals inaccessible to UC |
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Firearms (if applicable) inaccessible to UC |
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Medical supplies/prescriptions inaccessible to UC |
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Other unsafe areas inaccessible to UC |
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Fire extinguishers and smoke alarms in working order (test) |
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Pets? (clean/dangerous) |
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Playground/outdoor equipment (if applicable) appears safe and age appropriate |
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Outdoor area secure (fences in good repair, pool, supervised access) |
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Carbon Monoxide detectors (if applicable, gas fuel in home) |
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Compliant? |
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Y |
N |
n/a |
Confidential UC information in a secure location |
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Only individuals with a need to know basis have access to the case files |
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Private place for UC to make phone calls (if applicable) |
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Clean and Safe (windows/door locks) |
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Kitchen |
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Child-friendly (e.g. no safety/trip hazards) |
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UC dietary restrictions posted/accessible |
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Home is properly maintained (including furniture) |
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Food stored in a sanitary manner |
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Infants/toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers) |
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Knives/sharp objects inaccessible to youth |
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Well-ventilated |
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Adequately heated/cooled |
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Bathrooms |
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Child-to-parent ratio met |
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Soap |
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Toilet paper |
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Bedrooms |
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Working toilets |
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Separate by gender (per state licensing) |
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Hot/cold water |
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Natural light/dark at night |
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Appropriate privacy |
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Private place to store personal items/clothing |
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Hygiene/grooming items |
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UC provided appropriate clothing/footwear |
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Towels |
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Provision of appropriate linens |
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Adequately accommodate all UC |
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Phone numbers for UC to report sexual abuse/harassment (best practice) |
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Grievance procedures posted |
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Program rules posted |
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Extra copies of UC grievance forms |
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Foster home rules |
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Evacuation procedures posted prominently on each floor |
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Foster Home Monitoring Checklist – Other
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Observed? |
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Observed? |
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Services to Potentially Observe |
Y |
N |
n/a |
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Y |
N |
n/a |
Recreation – large muscle, outdoors |
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Chore assignments |
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Meals |
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Reviewed? |
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Logs/Schedules to Potentially Review |
Y |
N |
n/a |
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UC documents maintained by the foster parent (phone logs, prescription logs, recreation logs/calendar, fire drill logs etc.) |
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Other Notes |
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1 Unlicensed Facility Quarterly Health and Safety Visits are performed for long-term group homes. ORR does not operate unlicensed long-term foster care or transitional foster care programs.
THE
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF
PUBLIC BURDEN: The purpose of this information collection is to
allow ORR contractor monitors staff to document their findings
during the walkthrough portion of quarterly site visits. Public
reporting burden for this collection of information is estimated to
average 4 hours per response, including the time for reviewing
instructions, gathering and maintaining the data needed, and
reviewing the collection of information. This is a mandatory
collection of information (Homeland Security Act, 6 U.S.C. 279). An
agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information subject to the requirements
of the Paperwork Reduction Act of 1995, unless it displays a
currently valid OMB control number. If you have any comments on
this collection of information please contact UCPolicy@acf.hhs.gov.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2024-07-20 |