| |
Combined In-Home Contracts: Semi-Annual Quality Assurance Report |
03-2024 |
English (Word)
|
|
|
| |
File Checklist (Kinship License) |
|
English (Word)
|
|
|
| |
Provider Change Form |
|
English (PDF)
|
|
|
| |
Provider Direct Deposit Authorization Form |
|
English (PDF)
|
|
|
| |
Provider Registration Form |
|
English (PDF)
|
|
|
| |
State Fiscal Quarterly Report |
|
English (Excel)
|
|
|
| 00-002 |
COVID- 19 Prevention, Intervention and Quarantine Plan |
|
English (Word)
|
|
|
| 00-005 |
HVSA Expansion Application Template |
|
English (Word)
|
|
|
| 00-005A |
2022 Spring HVSA Tribal Expansion Funding Application |
|
English (Word)
|
|
|
| 00-005b |
2023 HVSA Application for Funding Home Visiting Exploration Planning |
|
English (Word)
|
|
|
| 00-020 |
5th Annual DCYF Indigenous Children, Youth, and Families (ICYF) Conference |
07-2024 |
English (Word)
|
English |
|
| 02-003 |
Application for Early Learning Advisory Council |
|
English (Word)
|
|
|
| 02-003a |
Application for Provider Supports Subcommittee |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 02-003b |
Parent Advisory Group (PAG) Application |
|
English (Word)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 02-020 |
Guide to Background Checks |
|
English (PDF)
|
|
|
| 02-026 |
Unsung Hero Nomination Form |
09-2024 |
English (Word)
English (PDF)
Somali (Word)
Spanish (Word)
|
|
|
| 02-027 |
Fall HVSA Expansion Letter of Intent to Apply |
09-2024 |
English (Word)
English (PDF)
|
|
|
| 02-028 |
Fall HVSA Supporting Children & Families (ESSB6109) Letter of Intent to Apply |
09-2024 |
English (Word)
English (PDF)
|
|
|
| 02-029 |
Fall HVSA Start-Up Letter of Intent to Apply |
09-2024 |
English (Word)
|
|
|
| 02-031 |
WA State Citizen Review Panels (CRP) Data Request Form |
|
English (Word)
|
|
|
| 02-206 |
Statement of Earnings |
|
English (Word)
English (PDF)
Albanian (PDF)
Spanish (PDF)
|
|
|
| 03-225 |
LICWAC Volunteer Application Checklist |
10-2024 |
English (Word)
English (PDF)
|
|
|
| 03-374B |
Agreement on Nondisclosure of Confidential Information-Non Employee |
|
English (Word)
English (PDF)
|
|
|
| 03-415 |
Facility Short Term Use Application |
|
English (Word)
English (PDF)
|
|
|
| 03-492 |
Foster Parent Recipient Shared Leave |
|
English (Word)
English (PDF)
|
|
|
| 03-493 |
Foster Parent Donor Shared Leave |
|
English (Word)
English (PDF)
|
|
|
| 04-220 |
Family Ancestry Chart |
|
English (Word)
English (PDF)
Tigrigna (PDF)
|
|
|
| 04-225 |
CBCAP Quarterly Report |
08-2024 |
English (Word)
Spanish (Word)
|
|
|
| 05-001 |
Expression of Interest |
|
English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 05-002 |
Funding Organization Commitment |
|
English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (PDF0
Spanish (Word)
|
|
|
| 05-003 |
Provider Application Form |
|
English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 05-004 |
ECEAP Community Funded |
|
English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 05-005 |
Education Appeal |
|
English (Word)
English (PDF)
|
|
|
| 05-006 |
ECEAP Pre-screen & Application (Combined Form) |
03-2024 |
English_2024-2025
Amharic_2024-2025
Arabic_2024-2025
Dari_2024-2025
Korean_2024-2025
Russian_2024-2025
Somali_2025-2025
Ukrainian_2024-2025
Vietnamese_2024-2025
Spanish_2024-2025
English_2024-2025_Pre-screen
Spanish_2024-2025_Prescreen
English_2024-2025_Application
Spanish_2024-2025_Application
|
|
|
| 05-007 |
ECEAP Contractor Financial Disclosure Certification |
|
English (PDF)
|
|
|
| 05-007A |
ECEAP Services Carryforward Plan |
|
English (Excel)
|
|
|
| 05-008 |
Early ECEAP Pre-screen and Application |
03-2024 |
English_2024-2025
Spanish_2024-2025
English_2024-2025_Pre-Screen
English_2024-2025_Application
|
|
|
| 05-009 |
ECEAP Professional Development Plan Assistant Teacher |
|
English (Word)
English (PDF)
|
|
|
| 05-010 |
ECEAP Professional Development Plan Lead Teacher |
|
English (Word)
English (PDF)
|
|
|
| 05-012 |
Approval of New Early ECEAP Site/Classroom |
|
English (Word)
|
|
|
| 05-021 |
ECEAP Contractor Alternative Attendance Plan Request |
|
English (Word)
English (PDF)
|
|
|
| 05-022 |
ECEAP Contract Waiver-Variance Request to ECEAP Requirements |
08-2024 |
English (Word)
|
|
|
| 05-024 |
ECEAP Contractor Equipment Disposal Request |
|
English (Word)
English (PDF)
|
|
|
| 05-026A |
ECEAP and B-3 Services Application |
|
Exhibit A: ECEAP and B-3 Services Application
Exhbit B: Letters of Support and Collaboration
Exhibit C: Coordination with Neighboring Head Start/ECEAP and Tribal Organizations (Scored)
Exhibit D: Budget
Exhibit F: Certifications and Assurances
|
|
|
| 05-027 |
ECLIPSE Services Application Packet |
|
Exhibit D: Startup Budget
Exhibit E: ECLIPSE Services Application Form
Exhibit F: Certifications and Assurances
|
|
|
| 05-031 |
Parent Consent to Transfer ELMS Records |
|
English (Word)
English (PDF)
Spanish (PDF)
|
|
|
| 05-032 |
ECEAP Complex Needs Fund Application FY 2024-25 |
|
English (Word)
|
|
|
| 05-033 |
Approval of New B-5 Subcontracts (ECEAP) 2023-2024 |
11-2023 |
English (Word)
|
|
|
| 05-034 |
ECLIPSE RFA Applications and Guides |
|
Request for Application References
Budget Form
ECLIPSE Request for Application Guide
ECLIPSE Minimum Service Delivery Requirements Table
|
|
|
| 05-035 |
ECEAP & Early ECEAP Parent & Family Voices (PFV) PFV Representative ("Rep") Recruitment |
|
English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 05-036 |
Verification of ECEAP Eligibility |
04-2024 |
English (Word)
|
|
|
| 05-037 |
ECLIPSE Prioritization Worksheet |
04-2024 |
English (Word)
|
|
|
| 05-041 |
Licensing Dvisions Practice Change Request Review & Approval |
|
English (Word)
|
|
|
| 05-041A |
Licensing Division Practice Change Request |
|
English (Word)
|
|
|
| 05-050 |
Citizen Review Panel Membership Application |
|
English (Word)
|
|
|
| 05-051 |
Citizen Review Panel Confidentiality Agreement |
|
English (Word)
|
|
|
| 05-052 |
ECEAP Contractor Professional Development Plan (PDP) Extension Request |
09-2024 |
English (Word)
|
|
|
| 05-060 |
Evidence Based Readiness Assessment |
08-2024 |
English (Word)
|
|
|
| 05-061 |
Combined In-Home Service (CIHS) Inquiry |
03-2024 |
English (Word)
|
|
|
| 05-065 |
Service Access and Civil Rights Complaint Form |
08-2024 |
English (PDF)
русскийَ (Russian fillable PDF)
Հայերեն (Armenian)
ييرب ع (Arabic)
中文 (Chinese)
درییر د ارسس فی (Farsi)
Samoa (Samoan)
Español (Spanish)
Українська (Ukrainian)
Tiếng Việt (Vietnamese)
|
|
|
| 05-100 |
Combined IN-Home Contracts: Semi-Annual Quality Assurance Report |
03-2024 |
English (Word)
|
|
|
| 05-101 |
Staff Selection Criteria for Evidence Based Practices (EBP's) |
03-2024 |
English (Word)
|
|
|
| 05-250 |
Certification Regarding Environmental Tobacco Smoke |
|
English (Word)
English (PDF)
|
|
|
| 05-305 |
ADA/504 Discrimination Complaint/Grievance Form |
|
English (PDF)
|
|
|
| 05-320 |
2018-19 Financial Disclosure Certification |
|
English (PDF)
|
|
|
| 05-325 |
ECEAP Porgram Monitoring Document Review Checklist |
|
English (Word)
English (PDF)
|
|
|
| 06-010 |
Electronic Attendance System Vendor Approved Checklist |
|
English (Word)
English (PDF)
|
|
|
| 06-025 |
Professional Services Billing Statement |
|
English (Word)
English (PDF)
|
|
|
| 06-097 |
Provider File Action Request |
10-2022 |
English (PDF)
|
|
|
| 06-160 |
Adoption Support Monthly Counseling Billing |
|
English (Word)
English (PDF)
|
|
|
| 06-165 |
Extended Foster Care (EFC) Denial Letter |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 06-166 |
Individual Training Plan |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 06-172 |
Domestic Violence Prevention Account |
|
English (Word)
English (PDF)
|
|
|
| 06-179 |
Education and Training Voucher (ETV) Spending Plan |
|
English (Excel)
|
|
|
| 07-019 |
Request for Modification of Current Guardianship Assistance Program (GAP) Subsidy Worksheet |
04-2024 |
English (Word)
|
|
|
| 07-020 |
ECEAP Service Purchase Request |
|
English (Word)
English (PDF)
|
|
|
| 07-035 |
Child Care Complex Needs Fund Verification |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 07-085 |
Client Travel Approval Quick Reference Guide |
03-2024 |
English (PDF)
|
|
|
| 07-090 Contact Forms Manager for translation revisions |
Caregiver Monthly Transportation Reimbursement |
03/2021 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 07-110 |
Child Care Stabilization Grant Application – Family, Friend, and Neighbor (FFN) License- Exempt Providers |
|
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 07-110A |
Child Care Stabilization Grant Spend Period Extension Request |
|
English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 07-110B |
Stabilization Grant Receipt Verification Form Program and Add-On Amounts |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 07-110C |
Stabilization Grant Receipt Verification Form Workforce Amounts |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 07-112 |
Spring 2021 Child Care COVID -19 Grant Receipt Verification |
|
English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 07-112a |
Early Achievers Needs-Based Grant Receipt Verification Form |
07-2024 |
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 08-050 |
Request/Certification of Data Destruction |
|
English (Word)
English (PDF)
|
|
|
| 09-007 |
Petition for Review of Initial Decision (Appeal) |
|
English (Word)
English (PDF)
|
|
|
| 09-008 |
Victim/Witness Notification Program Enrollment (save to your computer before filling out) |
|
English (PDF)
|
|
|
| 09-010 |
Child Welfare History |
|
English (Word)
|
|
|
| 09-012 |
Request for Certificate of Parental Improvement (CPI) |
|
English (Word)
English (PDF)
|
|
|
| 09-013 |
Vendor Affidavit of Lost, Stolen or Destroyed Warrant |
02-2022 |
English (Word)
English (PDF)
Portuguese (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-026 |
DSO & Jail Removal Data Form |
|
English (Word)
|
|
|
| 09-031 |
Authorization By Subject of Records Requested |
|
English (Word)
English (PDF)
|
|
|
| 09-041 |
Office of Tribal Relations Request for Qualified Expert Witness (QEW) |
09-041 |
English (Word)
|
|
|
| 09-042 |
Verification of Tribal Status: ECEAP & Early ECEAP Applicant |
08-2024 |
English (Word)
English (PDF)
|
|
|
| 09-054 |
Waiver of Notice of Further Hearing |
|
English (Word)
English (PDF)
|
|
|
| 09-056 |
Dependent/Ward of the Court Verification |
|
English (Word)
English (PDF)
|
|
|
| 09-082 |
Five Day Notification to Move |
|
English (Word)
English (PDF)
|
|
|
| 09-093 |
School Notification |
08-2024 |
English (Word)
Special Education Decision Make Flowchart
|
|
|
| 09-100 |
Hiring Education Affidavit Request (Early Learning) |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-101 |
Hiring Education Affidavit Request (School Age) |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-102 |
Hiring Education Affidavit Request (Outdoor Nature-Based) |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-104 |
ICPC Closure Letter |
|
English (Word)
English (PDF)
|
|
|
| 09-111 |
Continuous Quality Improvement Confidentiality Agreement |
|
English (Word)
English (PDF)
|
|
|
| 09-120 |
Local Indian Child Welfare Advisory Committee (LICWAC) Referral |
10-2024 |
English (Word)
|
|
|
| 09-121 |
Waiver of Right to Receive Written Information on Adoption Support Program Limitation |
|
English (Word)
English (PDF)
|
|
|
| 09-126 |
Local Indian Child Welfare Advisory Committee Confidentiality Agreement |
|
English (Word)
English (PDF)
|
|
|
| 09-127 |
Rights of Children and Youth in Foster Care |
|
English (Word)
English (PDF)
|
|
|
| 09-128 |
Child Fatality Case Review Confidentiality Agreement |
|
English (Word)
English (PDF)
|
|
|
| 09-129 |
Child Near Fatality Case Review Confidentiality Agreement |
|
English (Word)
English (PDF)
|
|
|
| 09-131 |
Background Check Request/Decision |
|
English (Word)
English (PDF)
Marshallese (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 09-132 |
Employee Background Check Request/Decision |
|
English (Word)
English (PDF)
|
|
|
| 09-133 |
Group Care, CPA and RPS Background Check Request/Decision Form |
09-2024 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-134 |
Relative Inquiry |
07-2024 |
|
English |
|
| 09-154 |
NCIC Purpose Code C Background Check Summary |
|
English (Word)
English (PDF)
|
|
|
| 09-160 |
Background Check Hearing Request Form |
|
English (Word)
English (PDF)
|
|
|
| 09-162 |
Background Check Reconsideration Request |
|
English (Word)
English (PDF)
|
|
|
| 09-164 |
Request for Early Learning Background Check Results |
03-2024 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 09-165 |
Portable Background Check Application |
03-2024 |
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-539 |
Inquiry to Indian Tribe |
|
English (Word)
English (PDF)
|
|
|
| 09-611 |
Release and Consent for Child Specific Recruitment |
|
English (Word)
English (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 09-653 |
Background Check Authorization |
|
English (Word)
English (PDF)
Amharic (PDF)
Cambodian (PDF)
Chinese (PDF)
Chinese (PDF)
Korean (PDF)
Laotian (PDF)
Maay Maay (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 09-761 |
Indian Identity Request |
|
English (Word)
English (PDF)
|
|
|
| 09-765 |
Declaration of Adoption Facilitator - Indian Child |
04-2023 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 09-837 |
Disclosure of Confidential HIV / AIDS Information |
|
English (Word)
English (PDF)
|
|
|
| 09-966 |
Authorization to Release Information to the Court |
|
English (Word)
English (PDF)
|
|
|
| 09-997 |
Adoption Support Worksheet |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Ukrainian (PDF)
Vietnamese (PDF)
|
|
|
| 09-998 |
Application for the Adoption Support Program and/or Reimbursement of Adoption Finalization Costs |
|
English (Word)
English (PDF)
Ukrainian (PDF)
Vietnamese (PDF)
|
|
|
| 10-011 |
Staff Roster for Child Placing Agency (CPA) |
07-2024 |
English (Word)
|
|
|
| 10-012A |
Personnel File Checklist for CPA: Executive Director/Administrator |
07-2024 |
English (Word)
|
|
|
| 10-012B |
Personnel File Checklist for CPA: Program Manager |
07-2024 |
English (Word)
|
|
|
| 10-012C |
Personnel File Checklist for CPA: Licensor |
07-2024 |
English (Word)
|
|
|
| 10-012D |
Personnel File Checklist for CPA: Case Manager |
07-2024 |
English (Word)
|
|
|
| 10-012E |
Personnel File Checklist for CPA: Case Aide |
07-2024 |
English (Word)
|
|
|
| 10-012F |
Personnel File Checklist for CPA: Consultant |
07-2024 |
English (Word)
|
|
|
| 10-012G |
Personnel File Checklist for CPA: Volunteer/Interns working directly with chldren |
07-2024 |
English (Word)
|
|
|
| 10-016 |
File Checklist and Certification for License of Foster Home |
06-2024 |
English (Word)
|
|
|
| 10-018b |
Kinship Home Study Update |
09-2024 |
English (Word)
|
|
|
| 10-035 |
Receiving Care Transition Summary |
12-2023 |
English (Word)
|
|
|
| 10-036 |
Emergent Placement Services (EPS) Transition Summary |
01-2024 |
English (Word)
|
|
|
| 10-042 |
Child Protective Services Casework Checklist |
|
English (Word)
English (PDF)
|
|
|
| 10-043 |
Home Study |
12-2023 |
English (Word)
Amharic (PDF)
Samoan (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
Tigrigna (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 10-045 |
Policies and Procedures for Child Placing Agency (CPA) Foster Care |
07-2024 |
English (Word)
|
|
|
| 10-045A |
Policies and Procedures for Child Placing Agency (CPA) Adoption Only |
07-2024 |
English (Word)
|
|
|
| 10-045B |
Policies and Procedures for Group Care |
|
|
|
|
| 10-046 |
Budget for Child Placing Agency (CPA) |
07-2024 |
English (Word)
|
|
|
| 10-046B |
Budget for Group Care |
|
|
|
|
| 10-048 |
Adoptive Parent and Child Checklist for Child Placing Agency (CPA) |
11-2023 |
English (Word)
|
|
|
| 10-049 |
Site Inspection Checklist (Health & Safety) for Child Placing Agency (CPA) |
11-2023 |
English (Word)
|
|
|
| 10-055 |
Group Receiving Center Checklist |
|
|
|
|
| 10-056 |
Initial/Kinship License Request for Tribes |
03-2024 |
English (Word)
|
|
|
| 10-057 |
Family Home Child Care Floor Plan Sketch Guide |
05-2024 |
English (Word)
English (PDF)
|
|
|
| 10-060 |
Residential Private Schools (RPS) Licensing Checklist |
10-2024 |
10-060.docx
|
|
|
| 10-061 |
Child’s Registration |
|
English (Word)
English (PDF)
|
|
|
| 10-082 |
Adoption Support Modification Worksheet |
01-2024 |
English (Word)
English (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 10-083 |
Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Assessment |
|
English (Word)
English (PDF)
|
|
|
| 10-114 |
Adoption Data Card |
|
English (Word)
English (PDF)
|
|
|
| 10-166A |
Behavioral Rehabilitation (BRS) Referral |
|
English (Word)
English (PDF)
|
|
|
| 10-182 |
File Checklist (Foster License) |
06-2024 |
English (Word)
|
|
|
| 10-182A |
File Checklist (Unlicensed) |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-182B |
File Checklist (Provisional Expedited License) |
|
English (Word)
|
|
|
| 10-182C |
File Checklist (Kinship License) |
06-2024 |
English (Word)
|
|
|
| 10-183 |
Home Inspection Checklist (Licensed) |
|
English (Word)
Marshallese (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-214 |
Pre-Authorization For Services |
|
English (Word)
English (PDF)
|
|
|
| 10-248 |
Compliance Agreement |
11-2022 |
English (Word)
Spanish (PDF)
Spanish (Word)
|
|
|
| 10-248B |
Compliance Agreement for Child Placing Agency (CPA) |
11-2023 |
English (Word)
|
|
|
| 10-248C |
Compliance Agreement for Group Care |
11-2023 |
English (Word)
|
|
|
| 10-290 |
WAC Agreements |
03-2023 |
English (Word)
Amharic (PDF)
Oromo (PDF)
Somali (PDF)
Soninke (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 10-354 |
Home Study or Reassessment Application |
11-2022 |
English (Word)
Amharic (PDF)
Marshallese (PDF)
Maay Maay (PDF)
Oromo (PDF)
Samoan (PDF)
Somali (PDF)
Soninke (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 10-395 |
Intensive Family Service Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary |
|
English (Word)
English (PDF)
|
|
|
| 10-405 |
Foster Home Reassessment |
|
English (Word)
|
|
|
| 10-405B |
Foster Home Move Reassessment |
|
English (Word)
|
|
|
| 10-408 |
Application for Child Placing Agency (CPA) License |
07-2024 |
English (Word)
|
|
|
| 10-408B |
Application for Group Care License |
08-2024 |
English (Word)
|
|
|
| 10-408C |
Application for Residential Private School (RPS) License |
10-2024 |
English (Word)
|
|
|
| 10-416 |
Foster Home Monitoring Visit |
|
English (Word)
Spanish (PDF)
Spanish (Word)
|
|
|
| 10-419 |
Supervision Plan for Site Specific Conditions |
11-2022 |
English (Word)
Spanish (PDF)
Soninke (PDF)
|
|
|
| 10-425 |
Reference Questionnaire (Certified Respite) |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-428 |
Caregiver Support Plan |
|
English (Word)
English (PDF)
|
|
|
| 10-432 |
Extended Foster Care Program Participation Agreement |
05-2024 |
English (Word)
English (PDF)
|
|
|
| 10-453 |
Home Inspection Checklist (Kinship) |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-454 |
DCYF Caregiver Authorization |
|
English (PDF)
Laotian (PDF)
Mam (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 10-455 |
Medication Log |
02-2024 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-459 |
Courtesy Supervision Referral |
10-2024 |
English (Word)
|
|
|
| 10-462 |
User Application and Acknowledgement |
|
English (Word)
English (PDF)
|
|
|
| 10-463 |
FamLink Data Access Request / Change |
|
English (Word)
English (PDF)
|
|
|
| 10-464 |
FamLink Access Application and Acknowledgement |
|
English (Word)
English (PDF)
|
|
|
| 10-474 |
FAR Family Assessment |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Cambodian (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Vietnamese (PDF)
|
|
|
| 10-475 |
Early Invention Program (EIP) Exit Summary |
|
English (Word)
English (PDF)
|
|
|
| 10-477 |
Adoption Support Program Application Checklist |
|
English (Word)
English (PDF)
|
|
|
| 10-479 |
Early Intervention Program (EIP) 90 Day Review |
|
English (Word)
English (PDF)
|
|
|
| 10-479 |
Early Intervention Program (EIP) 90 Day Review |
|
English (Word)
English (PDF)
|
|
|
| 10-480 |
Comprehensive Family Evaluation |
|
English (Word)
English (PDF)
|
|
|
| 10-484 |
Youth Run Prevention Plan |
|
English (Word)
English (PDF)
|
|
|
| 10-490 |
Child Specific Contract or Extra Supervision Rate Proposal |
|
English Excel
|
|
|
| 10-500 |
Acknowledgement of Child’s Adoptive File Provided to Adoptive Family: |
|
English (Word)
Spanish (Word)
Somali (PDF)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 10-536 |
ICPC Parent Home Study |
11-2019 |
English (Word)
|
|
|
| 10-537 |
Interstate Compact for the Placement of Children (ICPC) Parent Home Study Information |
|
10-537
10-537
Spanish (PDF)
Spanish (Word)
|
|
|
| 10-539 |
Interstate Compact for the Placement of Children (ICPC) Reference Questionnaire for Parent Home Study |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-540 |
Project SafeCare Monthly Summary |
|
English (Word)
English (PDF)
|
|
|
| 10-545 |
Family Feedback Questionnaire |
|
English (Word)
English (PDF)
|
|
|
| 10-546 |
Adoption Archive Request for Non-Identifying Information |
|
English (Word)
English (PDF)
|
|
|
| 10-566 |
Contracted Health and Safety Visit Referral |
|
English (Word)
English (PDF)
|
|
|
| 10-567 |
Contracted Health and Safety Visit Report |
|
English (Word)
English (PDF)
|
|
|
| 10-586 |
Preauthorization for In-Home Services |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 10-606 |
Adoptive Parent Counseling Preauthorization for Services |
|
English (Word)
English (PDF)
|
|
|
| 10-650 |
ESIT Authorization for Release of Records |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Chinese (PDF)
Farsi (PDF)
Khmer (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 11-011 |
2022 Spring HVSA Expansion Funding Opportunity Letter of Intent to Apply |
|
English (Word)
|
|
|
| 11-011A |
HVSA Tribal Home Visiting Funding Opportunity Letter of Intent |
|
English (Word)
|
|
|
| 11-014 |
Family Resource Center Capacity Building Funding Opportunity |
|
English (Word)
|
|
|
| 11-015 |
CBCAP Returning Programs |
04-2024 |
English (Word)
|
|
|
| 11-016 |
Perinatal Mental Health Year-End Community Report Template |
|
English (Word)
|
|
|
| 11-017 |
Diaper Bank Partnership Quarterly Report Form |
|
English (Word)
|
|
|
| 11-018 |
Perinatal Mental Health Returning Program |
04-2024 |
English (Word)
|
|
|
| 11-019 |
Diaper Bank Concrete Good for Families Quarterly Report Form |
|
English (Word)
|
|
|
| 11-020 |
Tribal Fatherhood Support Program Funding Opportunity |
|
English (Word)
|
|
|
| 11-021 |
HV-BAT Supplemental Form |
|
English (Word)
|
|
|
| 11-022 |
Family Resource Center Capacity Building Work Plan |
09-2024 |
English (Word)
|
|
|
| 11-023 |
FRC Quarterly Report Form |
09-2024 |
English (Word)
|
|
|
| 11-024 |
Tribal Fatherhood Supports Project Plan |
09-2024 |
English (Word)
|
|
|
| 11-025 |
Option 1A |
|
English (Excel)
|
|
|
| 11-026 |
Option 1B |
|
English (Excel)
|
|
|
| 11-027 |
Option 2 |
|
English (Excel)
|
|
|
| 11-028 |
Tribal Fatherhood Quarterly Reports |
09-2024 |
English (Word)
|
|
|
| 11-029 |
Quarterly Reporting Tool - Stengthen Families Locally |
|
English (Excel)
|
|
|
| 11-030 |
Youth and Young Adult Housing Response Team Referral |
|
English (Word)
|
|
|
| 11-031 |
Strengthen Families Locally Priority Project Proposal |
|
English (Word)
|
|
|
| 11-032 |
Strengthen Families Locally (SFL) Budget Templatae |
|
English (Excel)
|
|
|
| 11-033 |
Fall HVSA Fall Start-Up Funding Opportunity Application |
09-2024 |
English (Word)
|
|
|
| 11-034 |
HVSA Expansion Funding Opportunity Application |
09-2024 |
English (Word)
|
|
|
| 11-035 |
HVSA Supporting Children & Families (ESSB6109) Application |
09-2024 |
English (Word)
|
|
|
| 12-001 |
Special Needs Child Care Rate Request |
08-2022 |
English (Word)
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Dari (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Lingala (PDF)
Marshallese (PDF)
Oromo (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tigrigna (PDF)
Ukranian (PDF)
Urdu (PDF)
Vietnamese (PDF)
Trukese (PDF)
|
|
|
| 13-001 |
Applicant Medical Report- Confidential |
09-2022 |
English (Word)
Oromo (PDF)
Samoan (PDF)
Spanish (Word)
Spanish (PDF)
Somali (PDF)
Soninke (PDF)
Tagalog (PDF)
Tigrigna (PDF)
Vietnamese (PDF)
|
|
|
| 13-001A |
Applicant Medical Self Report |
|
English (Word)
Marshallese (PDF)
Oromo (PDF)
Samoan (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 13-001B |
Applicant Mental Health Report |
|
English (Word)
Spanish (PDF)
|
|
|
| 13-041 |
Family Genetic and Medical History |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 13-200 |
Health & Safety Checklist |
|
English (Word)
|
|
|
| 13-904 |
Diabetes Care and Action Plan |
|
English (Word)
English (PDF)
|
|
|
| 13-907 |
Brief Assessment of Anxiety and PTSD: Caregiver/Parent |
|
English (Word)
English (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 13-908 |
Brief Assessment of Anxiety and PTSD: Child / Youth (SCARED) |
01-2024 |
|
|
|
| 14-001 |
Employment Verification for State Training |
07-2021 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 14-002 |
Trainer Observation Rubric |
|
English (Word)
English (PDF)
|
|
|
| 14-003 |
Trainer Observation Rubric (Self Paced) |
|
English (Word)
|
|
|
| 14-005 |
OJJDP Title II Pass Through Fund |
|
English (Word)
|
|
|
| 14-011 |
Enrollment Application Medical and Dental Benefits |
|
English (PDF) If using chrome, save form to desktop before filling in form
Somali (PDF)
Spanish (PDF)
|
|
|
| 14-011a |
Change Form Medical and Dental Benefits |
|
English (PDF)
Spanish (fillable PDF)
Somali (fillable PDF)
|
|
|
| 14-012 |
Consent for Release of Information |
05-2023 |
English (Word)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
French (PDF)
Gujarati (PDF)
Laotian (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Soninke (PDF)
Spanish (PDF)
Tamil (PDF)
Tigrigna (PDF)
Ukranian (PDF)
Vietnamese (PDF)
|
|
|
| 14-025 |
Early Achievers Extension Application |
|
English (Word)
Somali (Word)
Spanish (Word)
|
|
|
| 14-040 |
Non ECEAP Child Request for ECLIPSE Enrollment |
02/2024 |
English (Word)
|
|
|
| 14-224 |
Statement from Landlord/Manager |
01-2023 |
English (Word)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Dari (PDF)
Farsi (PDF)
French (PDF)
Japanese (PDF)
Karen (PDF)
Korean (PDF)
Laotian (PDF)
Lingala (PDF)
Mien (PDF)
Neplai (PDF)
Oromo (PDF)
Portuguese (PDF)
Punjabi (PDF)
Romanian (PDF)
Russian (PDF)
Rwanda (PDF)
Swahili (PDF)
Somali (PDF)
Soninke (PDF)
Spanish (PDF)
Tagalog (PDF)
Tigrigna (PDF)
Turkish (PDF)
Trukese (PDF)
Ukranian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 14-252 |
Employment Verification |
08-2022 |
English (Word)
English (PDF)
Albanian (PDF)
Amharic (PDF)
Burmese (PDF)
Cambodian (PDF)
Chinese (PDF)
Dari (PDF)
Farsi (PDF)
French (PDF)
Haitian-Creole (PDF)
Korean (PDF)
Lingala (PDF)
Mongolian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Swahili (PDF)
Tagalog (PDF)
Turkish (PDF)
Ukaranian (PDF)
Vietnamese (PDF)
Wolof (PDF)
|
|
|
| 14-255 |
Early Childhood Equity Grant Application |
02-2024 |
English (Word)
|
|
|
| 14-281 |
Source of Funds Application for Child in Placement |
|
English (Word)
English (PDF)
|
|
|
| 14-293 |
Title IV-E Initial Eligibility Determination Income Calculation Worksheet |
|
English (Word)
English (PDF)
|
|
|
| 14-319 |
IV-E Eligibility Determination for an Adoption Support Application |
|
English (Word)
English (PDF)
|
|
|
| 14-319A |
IV-E Eligibility Determination for Federal Funds for GAP, Guardianship Assistance Program |
|
English (Word)
English (PDF)
|
|
|
| 14-417 |
CCSP Application |
|
English (Word)
Albanian (PDF)
Amharic (PDF)
Chinese (PDF)
Dari (PDF)
French (PDF)
Korean (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
Vietnamese (PDF)
|
|
|
| 14-430 |
CCSP Child Care Reapplication |
08-2022 |
English (Word)
Albanian (PDF)
Arabic (PDF)
Burmese (PDF)
Cambodian (PDF)
Chamarro (PDF)
Chinese (PDF)
Dari (PDF)
Farsi (PDF)
French (PDF)
French (PDF)
Haitian-Creole (PDF)
Hindi (PDF)
Italian (PDF)
Korean (PDF)
Lingala (PDF)
Oromo (PDF)
Pashtu (PDF)
Portuguese (PDF)
Punjabi (PDF)
Russian (PDF)
Serbo Croation (PDF)
Somali (PDF)
Swahili (PDF)
Thai (PDF)
Tigringa (PDF)
Ukrainian (PDF)
Vietnamese (PDF)
|
|
|
| 14-434 |
Title IV-E Requirements for Out of State Foster Care Payments |
|
English (Word)
English (PDF)
|
|
|
| 14-435 |
Provider Employment Eligibility Verification |
|
English (Word)
English (PDF)
|
|
|
| 14-438 |
Stop Work |
10-2019 |
English (Word)
Amharic (PDF)
Arabic (PDF)
Chinese (PDF)
Dari (PDF)
Oromo (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 14-444 |
Child Health and Education Tracking Screening Report |
09-2023 |
English (Word)
Spanish (Word)
Spanish (PDF)
Trukese (PDF)
|
|
|
| 14-446 |
Declaration of Financial Status for Adoption Support Application |
|
English (Word)
English (PDF)
|
|
|
| 14-452 |
Financial Worksheet |
09-2022 |
English (Word)
English (PDF)
Marshallese (PDF)
Oromo (PDF)
Soninke (PDF)
Spanish (Word)
Spanish (PDF)
Somali (PDF)
Tagalog (PDF)
Vietnamese (PDF)
|
|
|
| 14-474 |
Shared Planning Meeting |
|
English (Word)
Spanish (Word)
Spanish (PDF)
Cambodian (PDF)
Chinese (PDF)
Korean (PDF)
Mandinka (PDF)
Russian (PDF)
Somali (PDF)
Swahili (PDF)
Thai (PDF)
Tigrinya (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 14-510 |
Certified Respite Provider Agreements |
|
English (Word)
English (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 14-512 |
Application for Certified Respite Provider |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (fillable PDF)
|
|
|
| 14-531 |
Education and Training Voucher (ETV) Program and Passport to Careers Program 2024 – 2025 Application |
08-2023 |
English (Word)
|
|
|
| 14-531A |
Education and Training Voucher (ETV) Program and Passport to Careers Program Application Consent |
|
English (Word)
English (PDF)
|
|
|
| 14-545 |
Extended Adoption Support Application |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 14-548 |
Independent (IL) / Transitional Living (TL) Grant Application |
|
English (Word)
English (PDF)
|
|
|
| 14-600 |
Interim Individualized Family Service Plans (IFSP) (ESIT) |
|
English (Word)
|
|
|
| 15-005 |
ESIT Health Care Referral Form |
|
English (Word)
English (PDF)
|
|
|
| 15-015 |
Child Care Subsidy Program Site Change Form |
|
English (Word)
English (PDF)
|
|
|
| 15-016 |
HVSA Local Implementing Agency Contact Update Form |
|
English (Word)
English (PDF)
|
|
|
| 15-027 |
Professional Services Referral |
|
English (Word)
English (PDF)
|
|
|
| 15-028 |
Psychological Services Referral |
|
English (Word)
English (PDF)
|
|
|
| 15-029 |
Psychiatric Services Referral |
|
English (Word)
English (PDF)
|
|
|
| 15-030 |
Substance Use Disorder Professional (SUDP) Referral |
04-2024 |
English (Word)
|
|
|
| 15-050 |
Confirmation of Individualized Family Service Plan (IFSP) Schedule |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Portuguese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-051 |
Declining One or More Early Intervention Services |
|
English
Amharic (PDF)
Arabic
Cambodian
Chinese
Farsi
Korean
Laotian
Punjabi (PDF)
Russian
Somali
Spanish
Tamil
Telugu (PDF)
Ukrainian (PDF)
Urdu
Vietnamese
|
|
|
| 15-052 |
Declining Participation in the ESIT Program |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Portuguese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-053 |
Formal Dispute Resolution Request |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Laotian (PDF)
Marshallese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-054 |
Notice and Consent for Evaluation/Assessment |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukranian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-055 |
Individualized Family Service Plan (IFSP) |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Telugu (PDF)
Tamil (PDF)
Ukranina (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-056 |
Notice of Consent for Initial Evaluation Assessment |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Laotian (PDF)
Mashallese (PDF)
Portuguese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telegu (PDF)
Ukranian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-057 |
Notice and Consent for Screening |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-058 |
Parent Prior Written Notice |
01-2019 |
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Portuguese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese (PDF)
|
|
|
| 15-059 |
Prior Written Notice Consent and Financial Information Forms |
|
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Portuguese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese
|
|
|
| 15-060 |
Adoption Purchase of Services Contracted Out of State Health and Safety Visit Report |
|
English (Word)
|
|
|
| 15-092 |
The Interstate Compact on the Placement of Children (ICPC) Placement Request - 100A |
|
English (Word)
English (PDF)
|
|
|
| 15-093 |
Interstate Compact on the Placement of Children (ICPC) Report on Child’s Placement Date or Change of Placement – 100B |
02-2023 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-209A |
Health/Mental Health and Education Summary |
|
English (Word)
English (PDF)
|
|
|
| 15-209C |
Visit Plan |
|
English (Word)
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tagalog (PDF)
Tigrigna (PDF)
Ukrainian (PDF)
Vietnamese (PDF)
|
|
|
| 15-210 |
Out of State Family Time Referral |
07-2024 |
English (Word)
|
|
|
| 15-245 |
LIMITED ENGLISH PROFICIENT (LEP)/DEAF CLIENT SERVICES LEP Client Service Record |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-258 |
Safety Assessment / Safety Plan Combined |
05-2023 |
English (Word)
Haitian-Creole (PDF)
Russian (PDF)
Somali (PDF)
Spanish (Word)
Trukese (PDF)
Trukese (PDF)
|
|
|
| 15-258A |
Safety Assessment |
|
English (Word)
|
|
|
| 15-258B |
Safety Plan |
05-2023 |
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-259A |
Case Plan |
|
English (Word)
English (PDF)
Chinese (PDF)
Korean (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 15-260 |
Parents Information Sheet for Shared Planning Meetings and Staffings |
|
English (Word)
English (PDF)
|
|
|
| 15-266 |
Child Protect Teams (CPT) Staffing Recommendations |
|
English (Word)
English (PDF)
|
|
|
| 15-267 |
Attendance and Confidentiality Agreement |
|
English (Word)
English (PDF)
Vietnamese (PDF)
|
|
|
| 15-268 |
Child Protect Teams (CPT) Case Presentation Summary |
|
English (Word)
English (PDF)
|
|
|
| 15-276 |
Personal Information |
|
English (WORD)
Marshallese (PDF)
Samoan (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
Tagalog (PDF)
Tigrigna (PDF)
Trukese (PDF)
|
|
|
| 15-280 |
Unlicensed Caregiver Placement Checklist |
06-2023 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-281 |
Placement Agreement |
07-2023 |
English (Word)
Arabic (PDF)
Chinese (PDF)
Russian (PDF)
Somali (PDF)
Soninke (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-286 |
Reference Questionnaire |
01-2023 |
English (Word)
English (PDF)
Arabic (PDF)
Marhsallese (PDF)
Russian (PDF)
Spanish (Word)
Somali (PDF)
Spanish (PDF)
Tagalog (PDF)
Vietnamese (PDF)
|
|
|
| 15-286A |
Adult Child Reference Questionnaire |
|
English (Word)
English (PDF)
Arabic (PDF)
Marshallese (PDF)
Spanish (PDF)
Tagalog (PDF)
|
|
|
| 15-300 |
Child Information and Placement Referral |
|
English (Word)
English (PDF)
|
|
|
| 15-308 |
Missing Child Staffing |
|
English (Word)
English (PDF)
|
|
|
| 15-309 |
Returning Child De-Briefing |
|
English (Word)
English (PDF)
|
|
|
| 15-313 |
Caregiver's Report to the Court |
06-2023 |
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-313A |
Caregiver's Report to the Court (Abbreviated) |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-314 |
Combined In-Home Service Monthly Report |
08-2024 |
English (Word)
|
|
|
| 15-315 |
Transition Plan Meeting |
08-2024 |
English (Word)
|
|
|
| 15-322 |
Long Term Care Agreement for Foster Parents or Relative Caregivers |
|
English (Word)
English (PDF)
Mam (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-324 |
Guardianship Approval Checklist |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-349a |
Kinship Respite Overcapacity WAC 110-148-1390 |
|
English (Word)
|
|
|
| 15-359 |
Child's Physical Description |
|
English (Word)
English (PDF)
|
|
|
| 15-362 |
Concurrent TANF Benefits/Family Reunification Notice of Removal from TANF Home |
|
English (Word)
English (PDF)
|
|
|
| 15-363B |
Provider Notification of Visit/Transport Schedule Initial Intake Screening Report |
|
English (Word)
English (PDF)
|
|
|
| 15-363C |
Visit Coordination Plan |
|
English (Word)
English (PDF)
|
|
|
| 15-368 |
Education and Training Voucher (ETV) Program Participation Agreement |
|
English (Word)
English (PDF)
|
|
|
| 15-368A |
Education and Training Voucher (ETV) Program Dual Credit Participation Agreement |
|
English (PDF)
English (Word)
|
|
|
| 15-369 |
Education and Training Voucher (ETV) Program 2024 - 2025 Renewal Application |
08-2023 |
English (Word)
|
|
|
| 15-370 |
Education and Training Voucher (ETV) Program Payment Request |
|
English (Word)
English (PDF)
|
|
|
| 15-372 |
Enumeration Referral |
|
English (Word)
English (PDF)
|
|
|
| 15-377 |
Education and Training Voucher (ETV) Program Dual Credit Application |
|
English (Word)
|
|
|
| 15-386 |
Independent Living Learning Plan and Progress Report - IL Provider |
02-2024 |
English (Word)
|
|
|
| 15-402 |
Notice to Foreign Consulate of Child Protection Proceedings |
|
English (Word)
English (PDF)
|
|
|
| 15-411A |
Licensing Waiver (Foster Home) |
|
English (Word)
|
|
|
| 15-411D |
Administrative Approval (Foster Home) |
|
English (Word)
|
|
|
| 15-411G |
Kinship License Non-Safety Exemption/Waiver (Licensed Home) |
05-2023 |
English (Word)
Spanish (Word)
Spanish (PDF)
Trukese (PDF)
|
|
|
| 15-412 |
Request for Extension and Disability Verification for Youth Over Age 18 |
|
English (Word)
English (PDF)
|
|
|
| 15-416 |
Interstate Compact for Adoption Medical Assstance ICAMA |
|
English (Word)
|
|
|
| 15-417 |
Transition Plan for Youth Exiting Care |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-425 |
Adoption Redaction Request |
|
English (Word)
English (PDF)
Spanish (Word)
Somali (PDF)
Spanish (PDF)
Ukrainian (PDF)
Vietnamese (PDF)
|
|
|
| 15-428 |
Protective Action Plan |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Cambodian (PDF)
Chinese (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Vietnamese (PDF)
|
|
|
| 15-431 |
Extended Foster Care Program Voluntary Placement Agreement (VPA) |
05-2024 |
English (Word)
English (PDF)
Vietnamese (PDF)
|
|
|
| 15-434 |
On-Going Mental Health (OMH) Screening Report |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-448 |
Family Time Report |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-448A |
Supported Visit Report |
|
English (Word)
English (PDF)
|
|
|
| 15-448B |
Out of State Family Time Report |
07-2024 |
English (Word)
|
|
|
| 15-450 |
Child Specific Caregiver Notification |
|
English (Word)
English (PDF)
|
|
|
| 15-451 |
Missed and No Show Report: Parent – Child Visit |
|
English (Word)
English (PDF)
|
|
|
| 15-451B |
Out of State No Show/Cancellation Report |
07-2024 |
English (Word)
|
|
|
| 15-452 |
Sibling Visit Report |
|
English (Word)
English (PDF)
|
|
|
| 15-452B |
Out of State Sibling Visit Report |
07-2024 |
English (Word)
|
|
|
| 15-454 |
Unusual Incident Report |
|
English (Word)
|
|
|
| 15-454A |
Out of State Family Time Visit Unusual Incident Report |
07-2024 |
English (Word)
|
|
|
| 15-455 |
Vaccine Exemption |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (fillable PDF)
|
|
|
| 15-460 |
Background Confirmation and Out of State Check |
03-2024 |
English (Word)
|
|
|
| 15-466 |
Contract Risk Assessment / Analysis |
|
English (PDF)
|
|
|
| 15-469 |
Pre-Contract Action Request (P-CAR) |
|
English (Word)
English (PDF)
|
|
|
| 15-470 |
DCYF Regional Contract Request |
|
English (Word)
English (PDF)
|
|
|
| 15-472 |
After-the-Fact Contract Justification |
|
English (Word)
|
|
|
| 15-489 |
Placement Entry Tool |
|
English (Word)
English (PDF)
|
|
|
| 15-491 |
Plan of Safe Care |
|
English (Word)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Korean (PDF)
Laotian (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Vietnamese (PDF)
|
|
|
| 15-703 |
Declaration of Compliance (for Outdoor Nature-Based Programs) |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-705 |
FFN Waiver Request |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-707 |
School-Age Child Care Monitoring Checklist |
|
English (Word)
English (PDF)
|
|
|
| 15-708 |
Child Care Center Monitoring Checklist (Example) |
|
English (Word)
|
|
|
| 15-709 |
Family Home Child Care Monitoring Checklist (Example) |
|
English (Word)
|
|
|
| 15-716 |
Benefit-Risk Assessment and Mitigation Development for Outdoor Nature-Based (ONB) Child Care Programs |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-720 |
Interest Survey for Organization License Pilot |
|
English (Word)
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 15-820 |
Tuberculosis (TB) Screening LD |
06-2023 |
English (Word)
English (PDF)
Soninke (PDF)
Spanish (PDF)
Spanish (Word)
Trukese (PDF)
|
|
|
| 15-821 |
Infant Safety Agreement |
|
English (Word)
Marshellese (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
Vietnamese (PDF)
|
|
|
| 15-821a |
Infant Safety Certified Respite |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-822 |
Influenza Vaccination Agreement |
09-2022 |
English (Word)
Somali (PDF)
Soninke (PDF)
Spanish (Word)
Tigrigna (PDF)
Vietnamese (PDF)
|
|
|
| 15-822a |
Vaccine Agreements Certified Respite |
|
English (Word)
English (Word)
Spanish (Word)
Spanish (fillable PDF)
|
|
|
| 15-823 |
Pertussis Vaccination Agreement |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
|
|
|
| 15-824 |
Authorization and Consent to Share Records |
|
English (Word)
Spanish (Word)
Spanish (PDF)
Trukese (PDF)
Vietnamese (PDF)
|
|
|
| 15-824A |
Authorization and Consent to Share Records (CPA Home) |
|
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-824b |
Authorization and Consent to Share Records (Child Placing Agency/Group Care Staff) |
|
English (Word)
English (PDF)
|
|
|
| 15-826 |
Pet Vaccination Agreement |
06-2023 |
English (Word)
English (PDF)
Maay Maay (PDF)
Soninke (PDF)
Spanish (PDF)
Spanish (Word)
Trukese (PDF)
|
|
|
| 15-827 |
Kinship Caregiver iPad Equipment Checkout Agreement |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-835 |
Outdoor Nature-Based Child Care License or Certification Application |
01-2024 |
English (Word)
Spanish (Word)
Spanish (PDF)
Somali (PDF)
|
|
|
| 15-841 |
ONB Initial Checklist for Applicant |
|
English (Word)
|
|
|
| 15-845 |
ONB Monitoring Checklist (Example) |
|
English (Word)
|
|
|
| 15-852 |
Plan to Meet Experience Qualification |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-853 |
Intent to Transfer License or Certification |
|
English (Word)
English (PDF)
Somali (Word)
Somali (fillable PDF)
Spanish (Word)
Spanish (fillable PDF)
|
|
|
| 15-857 |
Parent/Provider Health Safety Agreement (FFN) |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-858 |
Emergency Contact and Permission Form (FFN) |
|
English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 15-859 |
Safety Record and Evacuation Plan |
|
English (Word)
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 15-860 |
Medication Permission Form For Illness and Allergies (FFN) |
|
English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 15-861 |
Initial Checklist for Child Care Center Applicant |
05-2023 |
English (Word)
|
|
|
| 15-862 |
Initial Checklist for Family Home Child Care Applicant |
05-2023 |
English (Word)
Ukrainian (PDF)
|
|
|
| 15-863 |
Initial Checklist for School-Age Program Applicant |
05-2023 |
English (Word)
|
|
|
| 15-874 |
Capacity Increase Change Planning Guide |
|
English (Word)
English (PDF)
|
|
|
| 15-879 |
Child Care Registration (fh/ctr) |
06-2021 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Ukrainian (PDF)
|
|
|
| 15-889 |
Sample Application for Employment or Volunteer Services Licensed or Certified Early Learning/Child Care Program |
|
English (Word)
English (PDF)
|
|
|
| 15-891 |
Chimney, Fireplace, Woodstove Use Statement |
09-2019 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Ukrainian (PDF)
|
|
|
| 15-892 |
Fire, Safety, Emergency Drills Record |
|
English (Word)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-893 |
Multiple Licenses Request Form |
|
English (Word)
|
|
|
| 15-894 |
Family Home Child Care Liability Insurance Form |
|
Engllish (Word)
English (PDF)
Somali (PDF)
Spanish PDF)
|
|
|
| 15-895 |
Overnight Child Care Planning Guide |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-896 |
Probation Notification Letter to Parents from Provider |
|
English (Word)
|
|
|
| 15-897 |
Child Care Parent Guardian Permissions |
|
English (Word)
English (PDF)
Somali (Word)
Spanish (Word)
|
|
|
| 15-899 |
Child Licensee or Assistant Resume |
|
English (Word)
English PDF)
Somali (PDF)
|
|
|
| 15-937 |
Child Care Center School-Age Background Checklist |
01-2024 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 15-941 |
Child Care Injury Incident Report |
|
Engllish (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Spanish (Word)
|
|
|
| 15-942 |
Daily Child Attendance Records |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-943 |
Child Care Agreement |
|
English (Word)
Spanish (Word)
|
|
|
| 15-944 |
School Based and Military Certification for Payment Only Request |
|
English (Word)
|
|
|
| 15-945 |
Tribal Certification Request |
|
English (Word)
|
|
|
| 15-949 |
Family Home Child Care Background Checklist |
09-2023 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-952 |
Notification to Parents and Guardian - Safe Sleep Non-Compliance |
|
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-954 |
Notification of Staffing Plan Absence |
|
English (Word)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-955 |
Family Home and Center Child Care License or Certification Application |
01-2024 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 15-956 |
No Social Security Card Declaration |
|
English (Word)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-957 |
Child Care Variance Request |
|
English (Word)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-961 |
Child Care Waiver Request |
|
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-963 |
Early Learning-Child Care Facility Feasibility Checklist |
|
English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 15-964 |
Early Learning-Child Care Facility Feasibility Checklist (sa) |
|
English (Word)
|
|
|
| 15-965 |
Sanitizer Disinfectant Approval Request |
|
English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
|
|
|
| 15-966 |
Child Care Health Consultant Agreement |
|
Engllish (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-967 |
Child Care Health Consultant Onsite Report |
|
English (Word)
Engllish (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-968 |
Child Care Medication Authorization |
06-2021 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Ukrainian (PDF)
|
|
|
| 15-969 |
Child Care Medication Log |
|
Englislh (Word)
Somali (PDF)
Spanish (PDF)
|
|
|
| 15-970 |
Individual Care Plan for Child in Child Care |
06-2021 |
English (Word)
English (PDF)
Spanish (PDF)
Ukrainian (PDF)
|
|
|
| 15-974 |
Declaration of Compliance |
12-2023 |
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
|
|
|
| 15-980 |
School Age License Application |
01-2024 |
English (Word)
English (PDF)
|
|
|
| 16-005 |
Electronice Attendance Provider Welcome Letter (Barcode) |
|
English (Word)
English (PDF)
|
|
|
| 16-010 |
Parental Advisory Group (PAG) Cover Letter and Application |
|
English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)
Spanish (Word)
|
|
|
| 16-015 |
State Approved Training Concern Form |
|
English (Word)
English (PDF)
|
|
|
| 16-025 |
Contractor Certification |
|
English (Word)
|
|
|
| 16-030 |
Book Review Worksheet for Foster Parent Training Hours |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 16-031 |
Staff Classroom Attendance Log |
04-2024 |
English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 16-179 |
Reference Questionnaire Request |
|
English (Word)
Marshallese (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 16-183 |
Emergency Respite Center Checklist |
01-2019 |
English (Word)
|
|
|
| 16-184 |
Maternity Services Checklist |
01-2019 |
English (Word)
|
|
|
| 16-185 |
Child Checklist (Health & Safety) for Child Placing Agency (CPA) |
11-2023 |
English (Word)
|
|
|
| 16-186 |
Crisis & Secured Crisis Residential Checklist |
01-2019 |
English (Word)
|
|
|
| 16-188 |
Medically Fragile and Children with Intellectual and Developmental Disabilities Checklist |
01-2019 |
English (Word)
|
|
|
| 16-189 |
Group Home Checklist |
01-2019 |
English (Word)
|
|
|
| 16-190 |
Overnight Youth Shelter Checklist |
01-2019 |
English (Word)
|
|
|
| 16-204 |
Emergency and Evacuation Plan |
06-2024 |
English (Word)
Samoan (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
|
|
|
| 16-209 |
Archived Records Memo Adoption and/or Legally Free Children Aged Out |
|
English (Word)
English (PDF)
|
|
|
| 16-217 |
Washington State ICPC Quarterly Supervision Report |
|
English (Word)
English (PDF)
|
|
|
| 16-225 |
File Checklist (Certified Respite) |
|
English (Word)
Spanish (Word)
Spanish (PDF)
|
|
|
| 16-235 |
Photo, Video or Audio Release Waiver |
|
English (PDF)
Chinese (PDF)
Somali (PDF)
Spanish (PDF)
|
|
|
| 17-041A |
Request for DCYF Records |
02-2024 |
English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
|
|
|
| 17-050 |
Guardianship Disclosure Request |
10-2024 |
English (Word)
|
|
|
| 17-063 |
Written Authorization |
|
English (Word)
English (PDF)
Amharic (PDF)
Vietnamese (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
Vietnamese (PDF)
|
|
|
| 17-215 |
DCYF Checklist: Subcontractor Approval Request |
|
English (Word)
English (PDF)
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| 17-215A |
DCYF Checklist: Subcontractor Approval Request |
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English (Word)
English (PDF)
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| 17-251 |
FERPA Access Request |
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English (Word)
English (PDF)
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| 18-400 |
Foster Caregiver Reimbursement Claim |
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English (Word)
English (PDF)
Spanish (Word)
Spanish (fillable PDF)
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| 18-400A |
Foster Caregiver Third Party Liability Claim |
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English (Word)
English (PDF)
Spanish (Word)
Spanish (fillable PDF)
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| 19-015 |
Workforce Retention Grant Verification Form |
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English (Word)
Spanish (Word)
Spanish (PDF)
Somali (PDF)
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| 20-015 |
Juvenile Rehabilitation Youth Engagement Request |
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English (Word)
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| 20-016 |
JR Marriage Approval for Release of Information |
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English (Word)
English (PDF)
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| 20-017 |
JR Marriage Application |
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English (Word)
English (PDF)
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| 20-020 |
Acknowledgement of JR Policy 6.70 Marriage in JR Facilities |
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English (Word)
English (PDF)
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| 20-270 |
Juvenile Justice System Improvement Technical Assistance Grant Application |
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English (Word)
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| 23-005 |
Three Pronged Approach (TPA) I. Parent Interview Questions Related to Vision and Hearing |
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English (Word)
Spanish (fillable PDF)
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| 23-006 |
Three-Pronged Approach (TPA) Developmental Skills Checklist Related to Vision and Hearing in Young Children |
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English (PDF)
Spanish (fillable PDF)
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| 23-007 |
Three-Pronged Approach (TPA) Summary Form Addressing Vision and Hearing Concerns |
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English (PDF)
Amharic (fillable PDF)
Arabic (fillable PDF)
Bengali (fillable PDF)
Cambodian (fillable PDF)
Chinese (fillable PDF)
Chinese Traditional (fillable PDF)
Dari (fillable PDF)
Farsi (fillable PDF)
French (fillable PDF)
Hindi (fillable PDF)
Japanese (fillable PDF)
Nepali (fillable PDF)
Pashtu (fillable PDF)
Portuguese (fillable PDF)
Punjabi (fillable PDF)
Russian (fillable PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
Tagalog (fillable PDF)
Telugu (fillable PDF)
Tamil (fillable PDF)
Tigrigna (fillablePDF)
Vietnamese (fillable PDF)
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| 23-032 |
In-State Child Abuse and Neglect Founded Findings Request |
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English (Word)
English (PDF)
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| 23-033 |
Child Abuse and Neglect Information Request |
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English (Word)
English (PDF)
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| 23-035 |
CHINS/ARY Report to Juvenile Court |
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English (Word)
English (PDF)
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| 23-036 |
Child Placing Agency Foster Home Licensing Investigation |
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English (Word)
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| 23-037 |
Background Clearance Notification |
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English (Word)
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| 23-041 |
Washington State Child Abuse and Neglect Founded Findings Request from Another State |
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English (Word)
English (PDF)
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| 23-046 |
ECEAP Program Monitoring Community Partner Questionnaire |
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English (Word)
English (PDF)
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| 27-164 |
Single Parent Declaration |
09-2020 |
English (Word)
English (PDF)
Albanian (PDF)
Amharic (PDF)
Arabic (PDF)
Burmese (PDF)
Chamarro (PDF)
Chinese (PDF)
Farsi (PDF)
Fijan (PDF)
Korean (PDF)
Lingala (PDF)
Marshallese (PDF)
Oromo (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Swahili (PDF)
Tigrinya (PDF)
Trukese (PDF)
Portugese (PDF)
Ukrainian (PDF)
Vietnamese (PDF)
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