MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION DIVERSION HOME AND SAFETY CHECKLIST
Name of Diversion Placement Provider:	Date:	Email Address:
Street	City	State	Zip Code
Telephone Number:	Other Number if applicable:
Work Address:	Work Telephone:
Work Address #2	Work Telephone #2:
Others In The Home
Name	Relationship to Diversion Placement Provider
A. Potential Diversion Placement Provider Personal Information
Have you or any household member ever:	Yes	No	Date occurred
Been convicted of a felony? If so, city and state:
Been convicted of a crime against person, a sexual offense, or crimes affecting family relationship and/or children? If so, city and state:
Committed an act of child abuse or neglect, as confirmed by Children’s Division? If so, city and state:
Have serious illness that is still contagious? If so, type of illness:
Been treated or diagnosed for chemical dependency and/or alcoholism?
Received a DUI/DWI or any drug related offense?
If there was answer of yes to any of the above, please attach a detailed explanation.
B. Care and Supervision of Youth
Will you:	Yes	No	Date answered
Cooperate with and follow the case plan for the child(ren) in your home?
Participate in all services identified as necessary to?
Assure regular school attendance and/or cooperate with the educational plan?
Provide supervision, nurturing and care of children?
Agree to use consistent, appropriate discipline and consequences?
Make the child(ren) in your home available to the Children’s Division to meet in person, virtually, or by other means of communication at least two times each month?
Allow the Children’s Division to inspect your home?
Allow the Children’s Division to meet with the child(ren) in your home?
Execute consents and releases of information as the Children’s Division deems necessary to obtain information to monitor the Immediate Safety Intervention Plan or Temporary Alternative Placement Agreement (TAPA)? Including, but not limited to schools, health care providers, and other professionals providing services.
Keep the Division informed of current address and other contact information?
Promptly notify the Children’s Division of any change in circumstance that may impact the care of the child or the implementation of an Immediate Safety Intervention Plan or Temporary Alternative Placement Agreement (TAPA)?
Provide truthful and accurate information to the Children’s Division and other members of the TDM?
Ensure any relative diversion placement provider and child reside in the State of Missouri? (Only applies to relative placements under a TAPA)?
C. Diversion Placement Provider Home
Physical and safety requirements:	Yes	No	Date Toured
Home appears clean and in good repair? Explanation:
Home has the space/capacity to accommodate the child(ren)? Explanation:
CD-278 (Safe Sleep Flyer) has been discussed, reviewed, and signed indicating that the provider is aware and understands safe sleep practices for children, ages two or younger, that are placed in their home. Explanation:
Flammable liquids, matches, cleaning supplies, poisonous materials medicines and other hazardous items are stored so as to be inaccessible to children. Explanation:
All medication (prescription, non-prescription or authorized) and all alcohol and/or medical marijuana, is enclosed in a locked container or cabinet, and stored so as to be inaccessible to children.
Weapons and ammunition are stored so as to be inaccessible to children. Ammunition and weapons are stored separately in locked areas or cabinets with keys secured so as to be inaccessible to children.
If weapons are present, the children’s service worker observed the storage of weapons and ammunition. Explanation:
There are no surveillance cameras in areas of the home that violate the privacy of the youth, e.g. bathrooms and dressing areas. Explanation:
Outdoor play space is 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. Explanation:
D. Health Care
Yes	No	Date Answered
Appropriate medical care will be provided for youth?
Diversion Placement Providers are in good health?
E. Policies relating to illness/emergencies
Emergency procedures	Yes	No	Date Answered
Agree to immediately report serious accidents, and/or illness, or deaths to the Children’s Division.
Agree to report suspected child abuse to the Child Abuse and Neglect Hotline at 1-800-392-3738 or online at https://dss.mo.gov/cd/keeping-kids-safe/can.htm
Agree to seek emergency medical attention if needed and inform the parent of actions taken.
F. COMMENTS
DIVERSION PLACEMENT PROVIDER SIGNATURE ►	DATE SIGNED
If applicable, a copy of the Official Notice of Temporary Placement of a Child (CD-294) was provided to the Diversion Placement Provider	Yes
DIVERSION PLACEMENT PROVIDER SIGNATURE ►	DATE SIGNED
If applicable, a copy of the Official Notice of Temporary Placement of a Child (CD-294) was provided to the Diversion Placement Provider	Yes
I have toured this home and reviewed this form with the diversion placement provider(s) and am of the opinion that the above information is accurate and that the home and the diversion placement provider(s) appear to meet physical standards of the home with any possible concerns and explanations noted above.
SIGNATURE OF CHILDREN’S SERVICE WORKER ►	DATE SIGNED
SIGNATURE OF CHILDREN’S SERVICE SUPERVISOR ►	DATE SIGNED