dhs-3130-a, RELATIVE PLACEMENT HOME STUDY

Michigan Department of Health and Human Services

(Revised 10-22)

section 1

Case Name	Caseworker Phone

Agency Name	Date Home Study Completed

Home Study Type Initial Annual Addendum

section 2 – CHILD INFORMATION

Child(ren) Names	Date of Birth	Caregiver Legal Relationship to Child

American Indian/Alaskan Native Heritage Yes No

section 3 – CAREGIVER INFORMATION

Caregiver(s) Name	Maiden Name, Aliases, AKA	Date of Birth

Social Security or Tax ID Number	Date of Central Registry Request

Date of Criminal History Background Check	Date of MPSOR Check

American Indian/Alaskan Native Heritage Yes No

Caregiver(s) Address	City	State	Zip Code

Caregiver(s) Phone Number	Caregiver(s) Email Address

section 4 – ADDITIONAL MEMBERS OF THE HOUSEHOLD

Name	Maiden Name, Aliases, AKA	Relationship to Caregiver

Date of Birth	Date of Central Registry Request

Date of Criminal History Background Check	Date of MPSOR Check

section 5 – CLEARANCES

Verification of Identity Any document which establishes the caregiver’s identity must be accepted. If documentary evidence is not readily available, use a collateral contact to verify identity.

Has the caregiver’s identity been verified? Yes No

Prior CPS Investigations Prior CPS history must be reviewed for all prospective caregivers. Director approval is required if the prospective caregiver was confirmed as a perpetrator in a prior investigation; see FOM 722-3B.

Date of clearance
Does the prospective caregiver(s) have a prior CPS investigation wherein he/she was an alleged perpetrator? Yes No
Was a caregiver confirmed as a perpetrator on a prior investigation? Yes No
The following caregiver(s) was confirmed as a perpetrator in a prior investigation
Describe the length of time since the prior confirmed investigation and any services that were provided.
If services were provided, document whether the caregiver(s) completed services successfully.
Address any risk factors that might impact the safety of the child and describe what protective interventions that are currently in place.

Central Registry Central Registry checks must be completed on all caregivers and adult household members. If a caregiver or an adult household member is listed as a perpetrator of abuse or neglect on Central Registry, director approval and the expunction of the caregiver/adult household member’s Central Registry history is required; see FOM 722-03B. Exception: When a parent on Central Registry resides or will reside in the relative home a recommendation may be made to approve placement. Director approval is required; see FOM 722-03B.

A caregiver or an adult household member is listed as a perpetrator of abuse or neglect on Central Registry? Yes No

The following adult(s) in the home is listed as the perpetrator on Central Registry.

A parent resides or will reside in the home and is listed on Central Registry? Yes No

If a parent on Central Registry resides or will reside in the home a safety plan must be established with the relative and documented below (Central Registry History Assessment not required in this instance):

Safety Plan

Central Registry History Assessment Identify the reason(s) for substantiation, the length of time since the substantiation, and any services that were provided to rectify the issue.

Assess the caregiver’s benefit from services provided. For example, if presented with a similar circumstance describe how the caregiver would handle the situation differently.
Document the status of the caregiver’s request for expungement.

Criminal History Background Checks Criminal history background checks must be completed on all caregivers and adult household members. All criminal history must be verified. Verification is accomplished by corroborating the information obtained from the criminal history background check with credible sources, e.g., ICHAT, Michigan Public Sex Offender Registry, police, or court records/personnel; see SRM 700.

If criminal history exists list the caregiver or adult household member’s name, offense, and date of conviction for all verified criminal history.
A caregiver or an adult household member has a felony conviction for one of the following offenses: Child abuse/neglect Spousal abuse Crime against children (including pornography). A crime involving violence, including rape, sexual assault or homicide but not including other physical assault or battery. A physical assault or battery within the last five years. A drug related offense within the last five years. Yes No If yes, placement is prohibited.
A caregiver or an adult household member is convicted of a good moral character offense as outlined in CWL-Pub-673, Good Moral Character. Yes No

If criminal history exists (excluding prohibited felony convictions or sexual offenses) the criminal history background assessment and director approval is required; see FOM 722-03B.

Criminal History Background Assessment Document the explanation for the conviction, the length of time since the conviction, and any services that were provided to rectify the issue.
Assess any benefit from services provided. For example, if presented with a similar circumstance describe how the caregiver/household member would handle the situation differently.
Assess and address any risk factors that might impact the safety of the child(ren) and describe the protective interventions and supports that are currently in place.

All caregivers and adult household members must have their name and address searched on the Michigan Public Sex Offender Registry. A caregiver or adult household member has been adjudicated or convicted of a sexual offense and is required to register as a sex offender. Yes No If yes, placement is prohibited.
A minor household member has been adjudicated or convicted of a sexual offense and is required to register as a sex offender. Yes No

If yes, the Minor Sex Offender Registry Assessment and director approval is required; see FOM 722-03B.

Minor Sex Offender Registry Assessment Document the explanation for the conviction, and length of time since the offense. Document any treatment that was provided to address the offense and assess whether the youth completed and benefitted from the treatment. Assess risk factors that may impact the safety of the child(ren) and describe the protective interventions and supports that are needed or currently in place and the caregiver's ability to provide protective interventions.

section 6 – RELATIVE PLACEMENT SAFETY SCREEN REVIEW

For initial or emergency placements that were made using the Relative Placement Safety Screen to approve the placement, complete the following questions.

On the Relative Placement Safety Screen, are there any concerns identified on the Placement Consideration Checklist or in the Placement Recommendation? Yes No
If yes, list the concern(s), list the action(s) taken to address the concern(s) (safety plan, resource acquisition, etc.) and for any unresolved concerns list the anticipated date of completion below:

section 7 – HOME AND GROUNDS ASSESSMENT

Living Space Describe the home, noting condition, layout, and appearance.
Is there at least one unobstructed entrance/exit on each floor being used as a living space, which leads to and from the home? Yes No
Are the basic utilities (water, electricity, heating) in operating condition? Yes No
Are the home and grounds free from observable health, sanitation, and safety hazards? Yes No
Does the home have running water and at least one toilet, sink, and tub or shower in operating condition? Yes No
Is there an accessible working phone in the home (including cell phone) or a working phone in close walking proximity? Yes No

If a safety concern was identified list the concern(s), list the action(s) taken to address the concern(s) and for any unresolved concerns list the anticipated date of completion below:

Safety Plan
Sleeping Arrangement and Bedrooms Describe the proposed sleeping arrangement for all caregivers, household members, and children in foster care.
Are there an adequate number of sleeping spaces (e.g., bed, crib, bassinet, pack and play) for the children in foster care? Related children over the age of 12 months may share a bed if developmentally and behaviorally appropriate. Yes No
Do the bedrooms occupied by children have a window that is large enough to be used for egress, permanently affixed walls and flooring that is acceptable for a living space? Yes No

If a safety concern was identified list the concern(s), list the action(s) taken to address the concern(s) and for any unresolved concerns list the anticipated date of completion below:

Safety Plan
Water Hazards Are there water hazards (e.g., swimming pool, hot tub, pond) on or near the premises? Yes No

If yes, provide an explanation of how the caregiver plans to safeguard children around the water hazard.

Safety Plan
Is there a safety plan in place to safeguard the children around the water hazard? Yes No NA
Pets Does the caregiver have pets? Yes No
Have the caregiver describe the pet’s temperament, vaccination history, and how the pet interacts with people.
If children in foster care are currently placed in the home, describe how the children have interacted with the pet.

Were concerns identified with the pet's temperament, vaccination history or how the pet interacts with people? Yes No

If a safety concern is identified, provide an explanation of how the caregiver plans to safeguard children around the pet.

Safety Plan

Weapons, Firearms and/or Ammunition Firearms must be stored unloaded, secured, and inaccessible to children. The ammunition must be stored separately. Note: Law enforcement officials who can provide documentation that their jurisdiction requires them to have ready and immediate access to their weapons may be exempt from these weapon requirements upon the completion and approval of a safety plan.

Are there weapons, firearms, or ammunition in the home? Yes No
Are the weapons, firearms, or ammunition inaccessible to children? Yes No NA
Specify the following Type (e.g., rifle, handgun, bow and arrow, bb gun)
Specify where the weapon, firearm, and ammunition are stored
How they are secured (e.g.: trigger locked/inoperable/cable lock/solid metal or solid wood gun safe)

If a safety concern is identified, provide an explanation of how the caregiver plans to safeguard children.

Safety Plan
Fire and Evacuation Plans Is there an operable carbon monoxide detector in the home and is there an operable smoke detector on each level of occupancy and near all sleeping areas in the home? Yes No
If no, describe the steps the caregiver will take to meet this requirement in the safety plan.
Is there an emergency evacuation plan in case of a fire? Yes No
If yes, briefly describe the evacuation plan and document how the caregiver shared the information with age-appropriate children in the safety plan.
If no, assist the caregiver in developing a plan, reviewing it with age-appropriate children, and document the details in the safety plan.
Safety Plan If applicable Describe the plan for the caregiver to obtain smoke alarms. Document the date the smoke alarms were/will be obtained. Describe the evacuation plan developed with the caregiver. Document the date the evacuation plan was reviewed with age-appropriate children.
Medication, Cleaning Supplies, and/or Dangerous Chemical Storage Children do not have access (as appropriate for age and development levels) to cleaning supplies, medicines, and/or other dangerous chemicals. Yes No
Describe where medications, cleaning supplies, and/or other dangerous chemicals are stored and include how this is appropriate given the child(ren)'s age and development level.

If a safety concern is identified, provide an explanation of how the caregiver plans to safeguard children.

Safety Plan

section 8 – FAMILY DYNAMICS, ATTITUDES, AND MOTIVATION ASSESSMENT

Caregiver For each caregiver, describe his/her current relationship status and provide a brief history of the relationship.
For each caregiver, describe his/her relationship and attitude toward the child(ren)’s parents.
For each caregiver, list the reasons for wanting to provide care for child(ren).
Describe how the caregiver(s) will discuss with the child(ren) the reasons they entered foster care.
Describe the caregiver’s willingness to participate and comply with the child(ren)’s case plan, including cooperation with the supervising agency, the parenting time plan, and the treatment plan.
Describe how the caregiver(s) will maintain significant relationships for the child(ren).
Are the caregiver(s) willing to supervise visits? Yes No
Are the caregiver(s) willing and able to provide for the child(ren) long-term, if necessary? Yes No
Child For each child currently living in the home, describe the following: Name, birthdate, race, school, and grade.
Date of placement.
Note any involvement with law enforcement or the criminal justice system.
Brief assessment of child’s adjustment, development, special needs, and relationship with parents.
Child’s description of the discipline techniques used in the family.
All household members For all caregivers and household members, describe their outlook on accepting a relative foster/adoptive child.
For all caregivers and household members describe the expected impact of fostering/adopting.

section 9 – PHYSICAL AND MENTAL HEALTH ASSESSMENT

All household members For all caregivers and household members (adults and children) describe the following: Current physical, mental, and emotional health status, including all prescribed medications and treatment.
Caregiver Does the caregiver(s) have a mental and/or emotional health condition that would impair his/her ability to provide for the child(ren)’s safety and well-being. Yes No
Does the caregiver(s) have a physical health condition that affects his/her ability to perform daily living activities (e.g., preparing meals, housekeeping, shopping for groceries, bathing) or care for the child(ren) in the home? Yes No
Does the caregiver(s) receive home health services or does the caregiver qualify for or receive SSI or RSDI due to a physical or mental disability? Yes No
If the caregiver has a current or a history of substance abuse/alcohol dependency indicate when and how it was diagnosed/determined and whether it has been resolved.

If a caregiver or a household member has an identified physical, mental, or emotional health need, list the concern and describe the safety plan.

Safety Plan

section 10 – FINANCIAL AND EMPLOYMENT ASSESSMENT

Describe the family’s financial and employment status, including the family’s sources and stability of income, resources, and expenses.
Are there adequate resources (earned/unearned income, monetary/non-monetary assistance, or benefit) to support the placement? Yes No
If the caregiver does not have adequate resources (earned/unearned income, monetary/non-monetary assistance, or benefits) to support the placement describe the resources needed to maintain the placement and the plan to obtain them.

section 11 – TRANSPORTATION ASSESSMENT

Does at least one caregiver have a reliable means of transportation (including public transportation)? Yes No

If the means of transportation is a personal vehicle, does the caregiver have a valid driver's license? Yes No NA

Does the caregiver have access to required safety seats if applicable? Yes No NA

If a concern is identified, list the concern, and describe the safety plan or the actions taken to resolve the concern.

Safety Plan

section 12 – CHILD CARE ASSESSMENT

Describe the plan for childcare, include the name and contact information of the alternate care provider.

section 13 – behavior management ASSESSMENT

Each child will have an individualized behavior management plan. Corporal punishment is prohibited. Does the caregiver agree to follow the behavior management plan developed with the supervising agency? Yes No
Does the caregiver agree to refrain from using corporal punishment on the children in foster care? Yes No
Have the caregiver describe behaviors that may require intervention.
Describe how the caregiver will intervene/handle these behaviors.

section 14 – infant care assessment

Complete this section if an infant 0-12 months was placed with the caregiver or if the caregiver is being considered for the placement of an infant 0-12 months of age. Has the caregiver been informed of safe sleep guidelines? Yes No NA
Was the caregiver provided the Infant Safe Sleep brochure? Yes No NA
Has the caregiver agreed to follow safe sleep guidelines? Yes No NA
Does the caregiver have a basic understanding of infant care? Yes No NA
Does the caregiver have the necessities and equipment to safely care for an infant (e.g., car seat, crib, child day care)? Yes No NA

If a concern is identified, list the concern, and describe the safety plan or the actions taken to resolve the concern.

Safety Plan

section 15 – PLACEMENT EXCEPTION REQUESTS (PER)

If placement occurs will there be more than three foster children in the caregiver’s home? If marked yes, a placement exception request must be completed; see FOM 722-03E. Yes No
If a placement occurs will there be more than five total children, including the caregiver’s birth and/or adopted children? If marked yes, a placement exception request must be completed; see FOM 722-03E. Yes No
If placement occurs will there be more than three children under the age of three residing in the caregiver’s home? If marked yes, a placement exception request must be completed; see FOM 722-03E. Yes No

section 16 – PLACEMENT recommendation

Do you recommend this caregiver for placement? Yes No
Provide rationale and explanation for placement recommendation.
Is this placement ordered by the court against the supervising agency’s recommendation? Yes No
If yes, provide rationale.

By signing below, I acknowledge my home had a home study completed.

Caregiver(s) Signature	Signature Date

Upon completion and approval all caregivers must be provided with a copy of the Relative Placement Home Study. Supervisor and director approval, if applicable, are recorded electronically in MiSACWIS.

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.