Package 7 Form J 02-2970c Disclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors Yes Package 7 Form J 02.A-2970c Executive Director Yes, if applicable. Package 7 Form J 02.B-2970c Chief Executive Officer Yes, if applicable. Package 7 Form J 02.C-2970c Comptroller Yes, if applicable. Package 7 Form J 02.D-2970c Chief Financial Officer Yes, if applicable. Package 8 Form K 03-2971c Request for Criminal History and DFPS History Check Yes Package 8 Form K 03.A-2971c Executive Director Yes, if applicable. Package 8 Form K Chief Executive Officer Yes, if applicable. Package 8 Form K 03.C-2971c Comptroller Yes, if applicable. Package 8 Form K 03.D-2971c Chief Financial Officer Yes, if applicable. Package 9 Form L 04-Form AP-152 Application for Identification Number Yes Package 10 Form M 06-Form 9007RCC Internal Control Structure Questionnaire (ICSQ) for Residential Child Care Yes Applicant Provides 06.A-Attachment I-2 If yes, submit most current financial statement; or If no, submit current financial position Yes Applicant Provides 06.B-Attachment I-2C If yes, submit most recent tax return Yes, if applicable. Applicant Provides 06.C-Attachment I-3 If yes, submit current Audit and Management letter (Only applicable to operations that have conducted annual audits) Yes, if applicable.
Applicant Provides 06.D-Attachment I-7A If yes, submit copy of IRS Audit Report; and Related IRS correspondence Yes, if applicable. Applicant Provides 06.E-Attachment I-7D Description of IRS discrepancies or liens impacting operation’s financial position Yes, if applicable. Applicant Provides 06.F-Attachment I-8 If yes, submit a description of discrepancies and/or unresolved issues with the State Auditor’s Office (SAO) Yes, if applicable. Applicant Provides 06.G-Attachment I-9 If yes, submit procedures describing your process for safeguarding and securing confidential information Yes, if applicable. Applicant Provides 06.H-Attachment III-14 Explain why foster family for all four (4) years are not included Yes, if applicable. Applicant Provides 06.I-Attachment III-15 Descriptions of Applicant’s processes for ensuring financial disbursement to foster families are made within ten (10) days of receipt of DFPS funds Yes, if applicable. Applicant Provides 06.J-Attachment III-17 If yes, submit a description of how your organization pays for Intermittent Alternative Care Yes, if applicable. Package 11 Form N 07-Form 9025a Related Party (Building & Transportation - Leases/Rental Worksheet) Yes FILE FOLDER 4: Service Level Monitor Attachments The following information to be organized in File Folder 4 as provided below. A DFPS License or RCCL acceptance letter. Complete set of program policies and procedures, and philosophy, including a substance abuse policy that indicates the Applicant will ensure substance abuse services will be provided for the Child, if needed. Substance abuse services can include referrals to outpatient/inpatient programs in the community, or substance abuse services provided through the Applicant's Operation. Submit all of your Operation’s Policies and Procedures.
Document Location ELECTRONIC FILE NAME Document Is Document Required Yes/No Applicant Provides 01-License DFPS License or acceptance letter Yes Applicant Provides 02-Model and Philosophy Program Model and Philosophy Yes Applicant Provides 02.A-Policies and Procedures Complete Set of Program Policies and Procedures Yes Applicant Provides 02.B-Substance Abuse Substance Policy and Procedure Yes Applicant Provides 03-Program Components Description of All Program Components Including Behavioral and Therapeutic Interventions Yes Applicant Provides 04-Children’s Orientation Children’s Rewards, Consequences and/or Orientation Manual/Handbook Yes Applicant Provides Schedules Example of Daily Schedules for School Year, Summer and Weekends Yes Applicant Provides 06-Recreation Schedule Example of Recreation Schedule Yes Applicant Provides 07-Therapeutic Value Description of Recreational Program, including its therapeutic value Yes Applicant Provides 08-School Relationship Written description of the relationship with the school system Yes Applicant Provides 09-Observation Plan to Provide Direct, Continuous Observation of a Child Who May Be at Risk for Harming Self or Others, and Awake Night Staff Based on the Child’s Needs Yes Applicant Provides 10-Professional Staffing Plan Professional Staffing Plan to Include Yes