MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION Notification of Hazards
Resource Provider Name(s):
DVN	Date:
I am/ We are providing Children’s Division notification of the following identified hazards within our home: Swimming Pool Trampoline Alcohol Weapons & Ammunition Prescriptions, non-prescriptions and authorized medicine Go Kart/ATV/buggy/scooter/other motorized recreational vehicle Parent one is a smoker Parent two is a smoker other individual(s) in the household smoke Flammable liquids, matches, cleaning supplies, poisonous materials, and other hazardous items Other (list) I am/ We are aware that the above listed items are hazardous and could cause serious injury or death.
I/We will maintain said hazardous items in compliance with all applicable city ordinances, state law or regulations, federal law or regulations, and/or Children’s Division policy or regulations.
I am/ We are in compliance with the following specific Children’s Division regulations: Pursuant to 13 CSR 35-60.030(7)(A), one of the listed minimum qualifications of foster parents is that “Foster parent structures environment so that it is safe and healthy for the child.” Pursuant to 13 CSR 35-60.40(1)(B), “The home shall be so constructed, arranged and maintained as to provide adequately for the health and safety of all occupants. It shall be of size and space and shall have furnishings and equipment to accommodate comfortably both the foster family and foster children in their care.” Pursuant to 13 CSR 35-60.40(1)(I), “The home shall have space for indoor and play and access to outdoor play space. The outdoor play space shall be fenced when in the judgment of the division, nearby street traffic, railroad tracks, lake, river, swimming pool, or other potential hazards suggest the necessity for such protection.” Pursuant to 13 CSR 35-60.050(11)(D), “The foster parent(s) shall notify the legal custodian immediately of emergencies involving the foster child. This requirement in no way relieves the foster parent(s) from first taking action, such as obtaining emergency medical treatment for the child before notifying his/her legal custodian. This includes serious illness or injury requiring medical treatment, unauthorized absence from the home or other situations in which sound judgment dictates that the legal custodian be notified.”
Signatures:
Resource Parent:	Date:
Resource Parent:	Date:
Resource Licensing Worker:	Date: