Foster Parent Forms

Foster Child Minimum Clothing Standards and Possessions List

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FOSTER CHILD MINIMUM CLOTHING STANDARDS
AND POSSESSIONS LIST
(email only)

This form must be completed when a child transitions in or out of your care. Below is the minimum wardrobe required. Indicate the number of items in good condition that fit well, and are seasonally appropriate.

Provider Name

Child Initials

Date:

Age of Child

Infants 0-1 Years Old 1-11 Years Old 12-14 Years Old 15-18 Years Old

Name of Person Sending Form

Email Address of Person Sending Form

Select the person at Family Alternatives
who you want to email the form to:

Select Recipient from Drop-Down List.

Incident Report Form

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INCIDENT REPORT FORM
(email only)

This form is not a substitute for the Notice of Incidence for the Foster Parent Liability Insurance.

Name of FA Social Worker

Child's Initials:

Child's Age:

Foster Home Name:

Date of Incidence:

Time of Incidence:

Incident:

Fighting Property Destruction Absenting Self-Inflicted Accidental Injury Chemical Abuse

Other:

Name(s) of Persons Notified

Name of Foster Parent Notified

Time of Notification

Date of Notification

Child County Worker

Time of Notification

Date of Notification

Parents of Child

Time of Notification

Date of Notification

FA Social Worker

Time of Notification

Date of Notification

Police (as needed)

Time of Notification

Date of Notification

Place. Coor. (as needed)

Time of Notification

Date of Notification

Other Person Notified

Time of Notification

Date of Notification

Brief Description of Incident:

Action Taken/ Resolution:

Foster Parent:

Date:

Family Alternatives Worker:

Date:

Family Alternatives Supervisor:

Date:

Name of Person Sending Form

Email Address of Person Sending Form

Who you want to email the form to?

Select Incident Report Recipient from drop-down list.

Respite Provider Information Form

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MAPCY Child Domains Ages 0-12

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MAPCY Youth Domains 13 and older

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Medical Mileage Reimbursement Form (MNet)

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Shelter Care Reimbursement Form

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Household Youth Safety Plan (MVA)

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HOUSEHOLD YOUTH SAFETY PLAN (MVA)
(email only)

Youth 18 and older placed in foster care are defined as vulnerable adults by the Minnesota Vulnerable
Adult Act (Minnesota Statutes 626.557), and must be provided a safe environment in the foster home.

Any suspected cases of abuse or neglect will be reported to the common entry point of

County, and/or local law enforcement at

Foster parents and any other adult responsible for supervision of youth will complete Vulnerable Adult Law training annually and maintain this Household Youth Safety Plan in the foster home.

The youth's Circle of Support/Support Team will assess vulnerability and risk of harm to others served by the program, and develop a Youth Safety Plan· for each youth 18 and older. The plan will guide appropriate supervision and provision of care.

Youth will be oriented to both plans within 72 hours of placement or their 18th birthday. Legal representatives of youth will be notified of the orientation.

Any risks in the foster home and environment are identified below with a plan to prevent abuse/neglect.

Possible Risk

Plan

Name of Person Sending Form

Email Address of Person Sending Form

Who do you want to email the form to?

Select Recipient from Drop-Down List

Reporting Policy (MVA)

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REPORTING POLICY (MVA)
(email only)

for:

Initials of Youth:

All youth in foster care over the age of 18 are considered to be vulnerable adults. As a mandated reporter, if you know or suspect that a vulnerable adult has been maltreated, you must report it immediately (within 24 hours).

Where to Report

Common Entry Point at:

Foster Parent:

When a foster parent receives a report he/she is responsible for deciding if the report must be forwarded to the common entry point. (If the foster parent is involved in the alleged or suspected maltreatment, you must report to youth's county or tribal social worker or probation officer.

Name:

at Number:

If you have reported to the foster parent, you will receive, within two working days, a notice that tells you whether or not your report has been forwarded to the common entry point. The notice will be given to you in a manner that protects your identity. It will inform you that, if you are not satisfied with the decision on whether or not to report externally, you may still make the external report to the common entry point yourself. It will also inform you that you are protected against any retaliation if you decide to make a good faith report to the common entry point.

Internal Review

When an internal or external report of alleged or suspected maltreatment has been made, an internal review will be completed and corrective action, if necessary to protect the health and safety of vulnerable adults will be taken. The internal review will include an evaluation of whether:

Policies and procedures were followed
Policies and procedures were adequate
There is a need for additional training
The reported event is similar to past events with the vulnerable adults or the services involved
There is a need for corrective action to protect the health and safety of vulnerable adults

Primary and Secondary Person to Ensure Reviews are Completed

The internal review will be completed by:

Foster Parent Name:

If the foster parent is involved in the alleged or suspected maltreatment, the Family Alternatives Licensing Social Worker,

FA Social Worker Name:

at 612-746-

Social Worker Phone extension number:

will be responsible for completing the internal review.

Documentation of Internal Review

Completion of the internal review will be documented, with a copy provided to the Commissioner upon the Commissioner's request.

Corrective Action Plan

Based on the results of the internal review, a corrective action plan designed to correct any current lapses and prevent future lapses in performance will be developed, documented, and implemented.

Signatures:

Youth

Foster Parent

County Social Worker

Family Alternatives Social Worker

Legal Representative

Name of Person Sending Form

Email Address of Person Sending Form

Select the person at Family Alternatives
who you want to email the form to:

Select Recipient from Drop-Down List.

Respite Request (SUBMIT WHEN RESPITE IS COMPLETED)

Respite Request

NOT TO BE SUBMITTED UNTIL RESPITE IS COMPLETED
(email only)

Name of FA Social Worker

Respite Provider

Name of Foster Parent

Number_Of-Children

Name(s) of Foster Children

From Date

To Date

Number of days to pay

Additional Notes:

Name of Person Sending Form

Email Address of Person Sending Form

Family Alternatives

Total: $

Total: $

Total: $