Foster Parent Forms

Foster Child Minimum Clothing Standards and Possessions List

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FOSTER CHILD MINIMUM CLOTHING STANDARDS
AND POSSESSIONS LIST
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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.

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who you want to email the form to:

Incident Report Form

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

Name(s) of Persons Notified

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Respite Provider Information Form

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RESPITE PROVIDER INFORMATION FORM
(email only)

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MAPCY Child Domains Ages 0-12
MAPCY Youth Domains 13 and older
Medical Mileage Reimbursement Form (MNet)

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MEDICAL MILAGE REIMBURSEMENT FORM (MNet)
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TRIP LOG
Questions? Call 651.645.9254 ext. 8172
Trip log must be submitted within 10 months of the date of service to be eligible for reimbursement.

RECIPIENT INFORMATION

MAKE CHECK PAYABLE TO:

(1) Starting Address (If home, write "HOME")
(2) Destination/Facility Info (Name, Address & Phone)
(3) Provider Type (i.e. pediatrician, 08/GYN, family practice)
(4) Name & Title of Healthcare staff who certifies the patient was seen for an MA billable service.

All requested information for each trip must be provided to ensure accurate and timely processing. Incomplete information may result in
non payment
.

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Shelter Care Reimbursement Form

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SHELTER CARE REIMBURSEMENT FORM
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Milage Reimbursement
Medical Reimbursement

Total: $

Babysitting

Total: $

Total: $

*Please submit to your Family Alternatives Social Worker weekly*

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Intensive Weekly Documentation Form

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INTENSIVE WEEKLY DOCUMENTATION FORM
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Household Youth Safety Plan (MVA)

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HOUSEHOLD YOUTH SAFETY PLAN (MVA)
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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

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Reporting Policy (MVA)

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REPORTING POLICY (MVA)
(email only)

for:

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

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.

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:

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

at 612-746-

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:

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