Resource Parent Screening Tool HOUSEHOLD COMPOSITION APPLICANT #1: At least 21?: YesNo APPLICANT #2: At least 21?: YesNo Household members over 14?: Any exotic pets or Pitbulls?: YesNo Do you have any guests/staff who frequent the home? YesNo If yes, are they able/willing to complete background checks/physical?: Relationship status: MarriedSingleDivorcedSeperated Are you able to provide documentation of marriage(s)/divorce(s)/separation agreement? YesNo Do you operate a child care center/assisted living unit/adult care from your home? YesNo EDUCATION/EXPERIENCE Does the applicant have a high school diploma/GED? YesNo Do you have previous foster care experience or work with youth? YesNo PHYSICAL HOME How many bedrooms/bathrooms in the home? How many bedrooms are available for youth to sleep? Will the youth be required to share a room, if so age/gender of youth sharing room: Do you have any pools/hot tubs/fountains, if so is the area fenced? Do you own any firearms? YesNo Do you have a license/permit? YesNo Do you agree to keep locked/stored separate from ammunition/away from children? YesNo Able to provide documentation of homeowners/renters insurance? YesNo Is your home equipped with functioning smoke alarms, sprinkler system (if installed), carbon monoxide detector? YesNo Willing to obtain/install bath mat, refrigerator/freezer thermometer, fire extinguisher with hose, bath mat or other required equipment? YesNo Does anyone in the home smoke? YesNo Foster care requires a smoke free environment for youth, are you willing to smoke outside of the home or in a separate room that the youth will not have access to? YesNo LEGAL Is either applicant listed on National Sex Offender’s Registry? YesNo Does either applicant anticipate any charges on (CBC)(MD/FBI), YesNo if yes explain Are you able/willing to complete the FBI full disclosure process (West Virginia)? YesNo Any charges in the past 5 years? YesNo Has either applicant/household member ever been charges with child abuse/neglect, sexual/physical assault, murder/manslaughter or any other charge involving harm to another person/animal? YesNo Are you or any adult household member currently on parole/probation? YesNo Has anyone in your home been indicated for child abuse/neglect (CPS)? YesNo FINANCIAL STABILITY Is your monthly income enough to meet your required expenses? YesNo Are you able to provide documentation of income/expenses? YesNo Do you have any outstanding debt which you are not able to provide documentation of payment arrangements? YesNo Do you have an open child support case (custodial/non-custodial parent)? YesNo Are payments current or arrangements made for past due amounts? YesNo HEALTH/MENTAL HEALTH Are all household members willing to complete physical/TB screening? YesNo Does any household member have any communicable diseases? YesNo Does any household member have a current physical/mental health/Substance abuse problem? YesNo Does any household member receive treatment/take medication? YesNo Is the applicant willing to give MPP/homes study worker consent to speak with treating professional and get physical/mental health clearance form signed? YesNo COMMUNITY/FAMILY RESOURCES Do you have access to transportation? YesNo Do you own/lease vehicle? YesNo Are you able to provide documentation of car insurance? YesNo Anyone in home have driver’s license?: YesNo Are there less than 3 points on record? YesNo Does your home have access to public transportation (on bus route, light rail, metro)? YesNo Do you have a neighbor and/or family support system? YesNo Are you able to identify community parks & recreation centers/PAL centers/churches/child care centers in your community (explain): Are you able to identify four people to comple a written reference form? YesNo Are you willing to consent to a written reference verification from your children’s school(s)? YesNo MATCHING Are you willing and able to accommodate males/females/both? What age youth between birth-20 are you willing to work? Are you willing to adopt? Are you willing to work with youth with mental health diagnoses? What special populations/behaviors are you willing to work with
