MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION STATISTICAL REPORT
NAME OF AGENCY	CALENDAR YEAR (January 1 through December 31)
Number of children placed for adoption
White
African American
Hispanic
Asian
Native American/Eskimo
Other
For International placements:
Asian
Asian Indian
Eastern European
South America
Other (List by Country)
Number of families who finalized adoption
White
African American
Hispanic
Asian
Native American/Eskimo
International
Other
Number of birth parents served who voluntarily relinquished parental rights
White
African American
Hispanic
Asian
Native American/Eskimo
Other
Number of birth parents served who chose to parent
White
African American
Hispanic
Asian
Native American/Eskimo
Other
For agencies providing International Adoption Services: a) list the countries of origin and number of children placed from each country; b) list any child placed that entered State of Missouri custody as a result of disruption or the dissolution of an adoption, including the plans for the child and reasons for the disruption or dissolution. Has your agency placed any children, either from a foreign country or from the United States, outside the fifty states? Yes No If yes, list the number of children and the country/territory of placement. Has your agency placed any Missouri children outside the State of Missouri? Yes No If yes, list the number of children and the country, territory or state of placement. List by name and departmental vendor number (DVN) any foster home or adoptive home revocations, disruption, or dissolution, during the year. List by name and address any active foster/adoptive family who had allegations of child abuse and neglect made to the Central Registry of the Children’s Division; and disposition, if known.

Form RPU-17, Statistical Report Directions

The purpose of Form RPU-17 is to obtain information pursuant to 13 CSR 40-73.012(6)(E)10 from licensed child placing agencies in the State of Missouri not tracked by FACES.

Number of Children Placed for Adoption.

The licensed child placing agency is requested to please enter the number of children placed for adoption. If the licensed child placing agency provided the adoptive home study only no entry is made.

Number of Families Who Finalized Adoption

The licensed child placing agency is requested to please enter the number of families for whom the licensed child placing agency provided post placement or post adoption services and the family finalized adoption. This includes families who were involved in international adoptions.

Number of Birth Parents Served Who Relinquished

The licensed child placing agency is requested to please enter the number of birth parents served who voluntarily relinquished parental rights. This includes both birth mothers and birth fathers

Number of Birth Parents Served Who Chose to Parent

The licensed child placing agency is requested to please enter the number of birth parents served who chose to parent. This includes both birth mothers and birth fathers. In some cases the birth mother may have chosen to parent by herself and likewise for the birth father.

Questions/Statements 1-5

The licensed child placing agency is requested to please answer these questions as they relate to the experience of the respective licensed child placing agency.

If needed the licensed child placing agency may submit additional information for clarification.