CHILD CHARACTERISTICS CHECKLIST FOR FOSTER CARE AND/OR ADOPTION
(Required for use with the JFS 01673)
Note: A person seeking to provide foster care or to adopt a minor who knowingly makes a false statement that is included in the written report of a home study conducted pursuant to Section 3107.02 or Section 5103.03 of the Revised Coed is guilty of the offense of falsification under Section 2921.13 of the Revised Code. A homestudy with a knowingly false statement shall not be filed with the court and if filed may be struck from the court's records.
Name of Applicant # 1
Name of Applicant # 2
Date completed or updated
Address of Applicant(s)
Name of Representing Agency and/or Agent
Address of Representative and/or Agent
221 W. Parish St. Sandusky, OH 44870
Instructions: Please print. Use the list below to let us know the type of child(ren) you would like to foster and/or adopt. Place an X in the appropriate box. If characteristics would be different for foster care than adoption, place an “A” for adoption and an “F” for foster care.
Positive toxicology screen at birth (one or more of the following: Cocaine, Amphetamines, Heroin, Morphine, Phencyclidine (PCP), Alcohol, Benzodiazepines, Hydromorphone, Marijuana, Propoxyphene, Methadone, Codeine)
Over age 17
Number of Children/Siblings
Prenatal Drug Exposure (one or more of the following: Cocaine, Amphetamines, Heroin, Morphine, Phencyclidine (PCP), Alcohol, Benzodiazepines, Hydromorphone, Marijuana, Propoxyphene, Methadone, Codeine)