MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN (ICPC) RECEIVING STATE’S PRIORITY HOME STUDY	ASSOCIATION OF ADMINISTRATORS OF THE INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN
EACH SECTION MUST BE COMPLETED
NAME OF CHILD TO BE PLACED	SENDING STATE
ETHNIC GROUP: White Hispanic Black Amer. Indian/Alaskan Native Other	DATE OF BIRTH	AGE
PROPOSED PLACEMENT RESOURCE
NAME	SOCIAL SECURITY NUMBER	HOME TELEPHONE NUMBER
ADDRESS	OTHER TELEPHONE NUMBER
MARITAL STATUS Married Single Divorced Widowed Separated	NAME OF CARETAKERS SPOUSE (or other adult household members, if applicable)
LENGTH OF RELATIONSHIP	SOCIAL SECURITY NUMBER
NUMBER OF MEMBERS IN HOUSEHOLD	RELATIONSHIP TO PROPOSED CARETAKER
EMPLOYERS NAME AND ADDRESS	WORK TELEPHONE NUMBER
SPOUSE’S EMPLOYERS NAME AND ADDRESS	WORK TELEPHONE NUMBER
RELATIONSHIP OF PROPOSED CARETAKER TO CHILD(REN) TO BE PLACED:
REASON FOR WANTING TO CARE FOR CHILD(REN):
DATES OF TELEPHONE CONTACT
DATES OF HOME VISITS
HOW DID PROPOSED RESOURCE HEAR ABOUT CHILD(REN)’S SITUATION?
IF THERE IS MORE THAN ONE (1) CHILD TO BE PLACED WITH THE PROPOSED CARETAKER, LIST THE NAME OF THE OTHER CHILDREN ON A SEPARATE PAGE AND ATTACH THAT INFORMATION TO THIS FORM.
PROPOSED RESOURCE’S UNDERSTANDING OF THE SITUATION WHICH CAUSED THIS REQUEST?
ABILITY TO PROTECT CHILD(REN) FROM OFFENDER, IF NECESSARY:
WILLINGNESS TO PROVIDE CARE (TIME LIMITED?) (OPEN ENDED?)
APPROPRIATENESS OF CHILD CARE PLANS:
FORMS OF DISCIPLINE: Signed Agency Discipline Policy: Yes No
YOU MUST SUBMIT INCOME VERIFICATION
INCOME $ CHECK ONE: YEARLY MONTHLY BIWEEKLY WEEKLY
HEAD OF HOUSEHOLD (NAME ON RENT RECIEPTS, UTILITY BILLS, ETC.)
IS PRESENT INCOME ADEQUATE FOR THE ADDITION OF CHILD(REN)? YES NO
WILLINGNESS (ABILITY) TO CARE FOR CHILD WITHOUT FINANCIAL HELP?	YES NO
WILLINGNESS TO ACCEPT/APPLY FOR PUBLIC ASSISTANCE (TANF/ FOODSTAMPS)?	YES NO
REQUESTS FOSTER CARE BENEFITS?	YES NO
WILLINGNESS TO BECOME LICENSED IF NECESSARY?	YES NO
SPECIAL NEEDS
ABILITY OF CARETAKER, COMMUNITY, SCHOOLS, TO MEET CHILDREN’S SPECIAL NEEDS
HOUSEHOLD COMPOSITION
LIST SEPARATELY/USE ADDITIONAL SHEET TO LIST HOUSEHOLD MEMEBERS IF NEEDED
NAME (Adult)	AGE	NAME (Adult)	AGE
RELATIONSHIP TO PROPOSED CARETAKER	RELATIONSHIP TO PROPOSED CARETAKER
RELATIONSHIP TO CHILD TO BE PLACED	RELATIONSHIP TO CHILD TO BE PLACED
FBI RESULTS FSCR CA/N CHECK	FBI RESULTS FSCR CA/N CHECK
ATTITUDE TOWARDS PLACEMENT	ATTITUDE TOWARDS PLACEMENT
NAME (Child)	AGE	NAME (Child)	AGE
RELATIONSHIP TO PROPOSED CARETAKER	RELATIONSHIP TO PROPOSED CARETAKER
RELATIONSHIP TO CHILD TO BE PLACED	RELATIONSHIP TO CHILD TO BE PLACED
ATTITUDE TOWARDS PLACEMENT	ATTITUDE TOWARDS PLACEMENT
SCHOOL PROGRESS / PROBLEMS: SCHOOL REFERENCE OBTAINED FOR EACH CHILD IN HOME? YES NO
PREVIOUS CONTACTS WITH PUBLIC /SOCIAL SERVICE AGENCIES: NO YES (IF YES PLEASE EXPLAIN BELOW)
CLEARANCES (IN ACCORDANCE WITH RECEIVING STATE LAW)
STATE STATUTE REQUIRES FBI FINGERPRINT SCREENINGS ON ALL ADULTS AGE 18 AND OLDER AS WELL AS CHILD ABUSE/ NEGLECT CLEARANCES.
FBI/ Mo STATE HIGHWAY PATROL CLEARANCES: No Record Found Criminal Record(explain/ list below)
CHILD ABUSE AND NEGLECT No Record Found Record Found (explain/ list below)
FAMILY KNOWN TO PUBLIC.SOCIAL SERVICES (IF YES, PLEASE EXPLAIN)
HEALTH
PROPOSED CARETAKER AND OTHER FAMILY MEMBERS STATE THAT THEY ARE IN BASIC GOOD HEALTH AND FREE OF COMMUNICABLE DISEASES YES NO DOCTOR’S STATEMENT OBTAINED? YES NO
HOME AND COMMUNITY
ADEQUACY OF SPACE
WILL THE CHILD HAVE HIS/HER OWN BED? YES NO CLOSET SPACE? YES NO WILL THE CHILD SHARE A BEDROOM? YES NO (IF YES, LIST NAME(S) AND AGES BELOW)
WITH WHOM?
HOUSEKEEPING STANDARDS:
POTENTIAL HAZARDS OR SAFETY ISSUES: NONE FOUND SAFETY ISSUES FOUND (please explain below)
APPROPRIATENESS OF NEIGHBORHOOD
PROXIMITY TO SCHOOLS, MEDICAL SERVICES, ETC.
AREAS OF CONCERN
DOES WORKER VISUALIZE OR ANTICIPATE ANY POTENTIAL PROBLEM AREAS WITH THIS CASE (EXPLAIN)? NO YES EXPLAIN BELOW:
CASE PLAN FROM SENDING STATE
IS THE PLACEMENT RESOURCE WILLING/ ABLE TO SUPPORT THE STATED CASE PLAN FOR CHILD(REN)? YES NO IF NO, EXPLAIN:
IS THE SUBMITTED CASE PLAN SUITABLE/ACCURATE FOR THIS PROPOSED PLACEMENT? YES NO IF NO, EXPLAIN BELOW:
ARE THERE ANY RECOMMENDED CHANGES OR ADDITIONS TO THE STATED CASE PLAN OR GOAL BY WORKER? NO YES IF YES, INDICATE BELOW
ARE THERE ANY RESTRICTIONS OR LIMITATIONS WORKER WOULD PLACE ON THE PROPOSED FAMILY, THE COURT, AND THE PLACING AGENCY? NO YES IF YES, PLEASE EXPLAIN BELOW:
IS THE FINANCIAL/ MEDICAL PLAN FROM SENDING STATE ADEQUATE TO MEE T THE NEEDS OF CHILD(REN)? YES NO IF NO, EXPLAIN BELOW:
STUDY NARRATIVE
DISCUSS ANY AREAS WHICH CANNOT BE ADDRESSED BY THE ABBREVIATED STUDY.
WORKER’S RECOMMENDATIONS FOR PLACEMENT AGAINST PLACEMENT IF AGAINST, EXPLAIN COMMENTS (IF APPLICABLE)
REFERENCES
NAME	MADE CONTACT? YES NO POSITIVE NEGATIVE
STREET ADDRESS	IF CONTACT NEGATIVE, EXPLAIN BELOW
CITY, STATE, ZIP
HOME TELEPHONE
WORK TELEPHONE
REFERENCES
NAME	MADE CONTACT? YES NO POSITIVE NEGATIVE
STREET ADDRESS	IF CONTACT NEGATIVE, EXPLAIN BELOW
CITY, STATE, ZIP
HOME TELEPHONE
WORK TELEPHONE
REFERENCES
NAME	MADE CONTACT? YES NO POSITIVE NEGATIVE
STREET ADDRESS	IF CONTACT NEGATIVE, EXPLAIN BELOW
CITY, STATE, ZIP
HOME TELEPHONE
WORK TELEPHONE
PLEASE LIST CONDITIONS, IF ANY, FOR PLACEMENT TO OCCUR
NAME OF WORKER (PLEASE PRINT)	SUPERVISOR (PLEASE PRINT)
SIGNATURE ►	SIGNATURE ►
TITLE	TITLE
DATE	TELEPHONE NUMBER	DATE	TELEPHONE NUMBER