Child characteristics checklist for foster care and/or adoption



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Ohio Department Of Job and Family Services

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)

     


Applicant’s Phone

     


Name of Representing Agency and/or Agent

ECDJFS


Phone

(419) 626-6781



Address of Representative and/or Agent

221 W. Parish St. Sandusky, OH 44870



Fax

(419) 624-6328



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.







Will

consider


Will not consider







Will

consider


Will not consider

Gender/Sex of Child




Race/Ethnicity/Language of Child

Female






American Indian or Alaskan Native





Male





Black or African American





Age of Child

White





Newborn/under 1





Asian





1





Native Hawaiian or Other Pacific Islander





2





Biracial (2 of the races above must be selected)





3





Multiracial (3 or more of the races above must be selected)





4





Unable to determine (applies to deserted child or safe haven baby only)





5





Hispanic or Latino Ethnicity





6





Non-English Speaking/specify language:      





7





Placement History

8





Child’s first placement: no known behavior problems





9





Child’s first placement: agency has no information on child





10





Child now in residential treatment





11





Child has had previous foster placement(s)





12





Child has had previous adoptive placement(s)





13





Birth History

14





Low birth weight or premature





15





Fetal Alcohol Syndrome





16





Fetal Alcohol Effects





17





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

1





2





Prenatal Drug Exposure (one or more of the following: Cocaine, Amphetamines, Heroin, Morphine, Phencyclidine (PCP), Alcohol, Benzodiazepines, Hydromorphone, Marijuana, Propoxyphene, Methadone, Codeine)





3





4





5 or more





Teen Parent with Child





Drug Addiction at Birth (heroin, methadone, morphine, or other)







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