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On-Site Review Instrument and Instructions

(APRIL 2002)

       

CHILD eligible for entire sample review period:

Yes

 

No

 

PROVIDER eligible for entire sample review period:

Yes

 

No

 
         

TITLE IV-E FOSTER CARE ELIGIBILITY REVIEW CHECKLIST

EACH QUESTION MUST BE ANSWERED. If the question is not applicable, check the N/A column. A question with N/A shaded must be answered YES or NO. Review the INSTRUCTIONS FOR COMPLETING THE TITLE IV-E FOSTER CARE ELIGIBILITY CHECKLIST for an explanation of each question and how to answer it. This form may be annotated with additional information regarding eligibility, as necessary. Boxes outlined in bold indicate potential case errors.

Sample review period (MM/DD/YY):

     
  1. State Abbreviation and Random Sample Selection number:
     
  1. Case ID:
 
  1. County or Local Office:
 
  1. Date of Review (MM/DD/YY):
 
  1. Reviewed by:
 

A. CHILD INFORMATION

YES

NO

N/A

X1. Child's Name:

     
  1. Child's Date of Birth (MM/DD/YY):
     
  1. Child's age as of first day of sample review period: ___________
     
  1. If this child was 18 at any time during the sample review period, was (s)he a full time student in secondary school or its equivalent and expecting to graduate prior to the 19th birthday? (State Option)
     

8(a). If the answer to question 8 is NO, was title IV-E claimed for the period of ineligibility?

     

B. RELEVANT DATES

  1. Date child was removed from home: (MM/DD/YY) ____/_____/____
 
  1. Date child entered foster care: (MM/DD/YY): _____/_____/_____
     

C. REMOVAL PURSUANT TO A COURT ORDER

  1. Was child's removal the result of a judicial determination? If NO, proceed to question 14. If YES, continue to question 12.
     

TITLE IV-E FOSTER CARE ELIGIBILITY REVIEW CHECKLIST

Case ID:

 
 

YES

NO

N/A

  1. Date of court order removing child from the home (MM/DD/YY): ________________
     

12(a). Does the removal order address CONTRARY TO THE WELFARE?

     
  1. Is there a court order that addresses REASONABLE EFFORTS TO PREVENT REMOVAL OR REASONABLE EFFORTS TO REUNIFY CHILD AND FAMILY?
     

13(a). Date of court order re: reasonable efforts to prevent removal (MM/DD/YY): ________

13(b). Date of court order re: reasonable efforts to reunify (MM/DD/YY): _____________

     

D. VOLUNTARY PLACEMENTS

     
  1. Was the child's removal pursuant to a voluntary placement agreement?

If YES, Continue to question 15.

If NO, proceed to question 17.

     
  1. Was the voluntary placement agreement signed by parent/legal guardian AND the agency representative(s)?
     

15(a). Date voluntary placement agreement was signed by all parties (MM/DD/YY):_____________

     
  1. Is there a judicial determination regarding the child's BEST INTEREST within 180 days of the date of placement?
     

16(a). Date of judicial determination (MM/DD/YY): _________________

     

E. ONGOING JUDICIAL ACTIVITY (APPLICABLE TO COURT-ORDERED REMOVALS ONLY)

  1. Is a judicial determination regarding REASONABLE EFFORTS TO FINALIZE THE PERMANENCY PLAN due during the period under review?
     

If NO, proceed to question 18. If YES, continue to question 17(a).

17(a). Date that the judicial determination was due (MM/DD/YY)______________

     

17(b). Date that the judicial determination was made (MM/DD/YY)____________

     

17(c). Was the judicial determination timely?

     

17(d). IF NO, indicate period of ineligibility. (MM/DD/YY) _______ to (MM/DD/YY) ________

   

TITLE IV-E FOSTER CARE ELIGIBILITY REVIEW CHECKLIST

Case ID:

 
 

YES

NO

N/A

F. AFDC ELIGIBILITY

  1. Date child last lived with parent/specified relative prior to current foster care episode (MM/DD/YY): ____________
     
  1. Was the child living with the specified relative at question 18 within 6 months of the initiation of court proceedings or the voluntary placement agreement?
     
  1. Was the child living with and removed from the same specified relative?
     
  1. Has the State determined that the child was AFDC-eligible at the time of removal?
     

21(a). Was financial need established?

     

21(b) Was deprivation of parental support or care established?

     
  1. Was the child's eligibility redetermined?

22(a). Date of redetermination, if applicable (MM/DD/YY): _________________

     
  1. Does financial need exist throughout the entire review period?
     

23(a). If NO, was title IV-E claimed for the period of ineligibility?

     
  1. Does deprivation exist throughout the entire review period?
     

24(a). If NO, was title IV-E claimed for the period of ineligibility?

     

G. STATE AGENCY RESPONSIBILITY FOR PLACEMENT/CARE OF CHILD

  1. For the entire time that the child is in an out-of-home placement during the review period, does the IV-E agency (or public agency with IV-E agreement) maintain responsibility for the placement and care of the child? If YES, proceed to question 27. If NO, continue to question 26.
     
  1. Was title IV-E claimed for the period of time that the title IV-E agency (or public agency with IV-E agreement) did not have responsibility for the placement and care of the child?
     
  1. Name of agency:
     

TITLE IV-E FOSTER CARE ELIGIBILITY REVIEW CHECKLIST

Case ID:

 
 

YES

NO

N/A

H. PLACEMENT IN LICENSED HOME OR FACILITY (Complete for EVERY home/facility during the review period)

X2. Provider Name:

     

X3. Provider Street Address:

     

X4. Provider City:

X5. Provider State:

     
  1. Date of child's placement in this foster care facility (MM/DD/YY):
     
  1. Date of child's departure from this facility, if applicable (MM/DD/YY):
     
  1. Type of foster care facility (check one): FFH ( ) GH ( ) Public Inst. ( ) PNP/FP Inst. ( ) Other ( )
     
  1. Is this provider licensed or approved for the entire time of the child's placement that falls within the period under review?
     

31(a). Licensed period

from (MM/DD/YY) ___________________

to (MM/DD/YY) ______________________

     

31(b). If NO, was title IV-E claimed for the period of time the provider is not licensed/approved?

     

I. SAFETY REQUIREMENTS OF PROVIDER

(Complete for EVERY home/facility during the review period)

  1. Has this State opted out of the criminal records check requirement? (This requirement applies only to prospective foster family homes and pre-adoptive homes.)

If YES, proceed to question 34.

If NO, continue with question 33.

     
  1. Was a criminal records check satisfactorily completed on the foster/adoptive parent(s)?
     
  1. If the State has opted out of the criminal records check requirement, does the licensing file contain documentation that safety considerations with respect to the caretaker(s) have been addressed?
     
  1. If the child is placed in a child care institution, does the licensing file contain documentation that safety considerations with respect to the staff/caretakers have been addressed?
     

State___________________ Case ID __________________ Eligible: YES NO

Licensing Checklist for Multiple Placements

Use this page to record multiple placements during the review period.

 

YES

NO

N/A

H. PLACEMENT IN LICENSED HOME OR FACILITY (Complete for EVERY home/facility during the review period)

X2. Provider Name:

     

X3. Provider Street Address:

     

X4. Provider City:

X5. Provider State:

     
  1. Date of child's placement in this foster care facility (MM/DD/YY):
     
  1. Date of child's departure from this facility, if applicable (MM/DD/YY):
     
  1. Type of foster care facility (check one): FFH ( ) GH ( ) Public Inst. ( ) PNP/FP Inst. ( ) Other ( )
     
  1. Is this provider licensed or approved for the entire time of the child's placement that falls within the period under review?
     

31(a). Licensed period

from (MM/DD/YY) ___________________

to (MM/DD/YY) ______________________

     

31(b). If NO, was title IV-E claimed for the period of time the provider is not licensed/approved?

     

I. SAFETY REQUIREMENTS OF PROVIDER

(Complete for EVERY home/facility during the review period)

  1. Has this State opted out of the criminal records check requirement? (This requirement applies only to prospective foster family homes and pre-adoptive homes.) If YES, proceed to question 34. If NO, continue with question 33.
     
  1. Was a criminal records check satisfactorily completed on the foster/adoptive parent(s)?
     
  1. If the State has opted out of the criminal records check requirement, does the licensing file contain documentation that safety considerations with respect to the caretaker(s) have been addressed?
     
  1. If the child is placed in a child care institution, does the licensing file contain documentation that safety considerations with respect to the staff/caretakers have been addressed?
     

ADDITIONAL NOTES/COMMENTS:

 

 



Instructions for Completing
the Title IV-E Foster Care Eligibility Checklist

["X" prefix indicates that information obtained for this field is confidential and will not be disclosed for any purposes outside the review.]

Sample review period: Record the beginning and ending date of the 6-month sample review period. This 6-month time frame corresponds to the Adoption and Foster Care Analysis and Reporting System (AFCARS) reporting period from which the sample was drawn.

  1. State abbreviation and random sample selection number: Record the two-letter State abbreviation and the sample selection number assigned to this case.


  2. Case ID: Record the case number that is used as the identifier by the State.


  3. County or local office: Record the name of the county, if applicable.


  4. Date of review: Record the date on which the case is being reviewed.


  5. Reviewed by: Record the name of the individual reviewing the case. Please print.
A.
Child Information

X1. Child's name: Record the first and last name of the child whose case is being reviewed.

  1. Child's date of birth: Enter the month, day and year of the birth of the child whose case is under review.


  2. Child's age as of first day of sample review period: Enter the age of the child on the first day of the sample review period. If child was born during the sample period, enter a zero. This field is not mandatory but is used to determine the appropriate foster care maintenance payment consistent with the State's rate payment schedule.


  3. If this child was 18 during the sample review period, was (s)he a full-time student in secondary school or its equivalent and expecting to graduate prior to the 19th birthday? When a child reaches his or her 18th birthday, eligibility for Aid to Families with Dependent Children (AFDC) ceases unless, at State option, the child is a full-time student in a secondary school or its equivalent and is expected to complete the program before age 19. If the State does not exercise this option, eligibility for title IV-E foster care ceases at the end of the month the child turns 18. If the State does exercise this option, eligibility for title IV-E foster care ceases at the end of the month the child leaves school. However, if circumstances occur that prevent the child's completion of secondary school or its equivalent, eligibility for title IV-E foster care ceases at the end of the month in which the child leaves school or when the child turns 19, whichever occurs earlier.

8a. If the answer to question number 8 is "no," was title IV-E claimed for the period of ineligibility? If title IV-E was claimed during the ineligible portion of the review period, the case is in error.

B.
Relevant Dates

Note that the relevant dates for this section may precede the sample review period.

  1. Date child was removed from home: Record the date of the child's most recent removal from the home of the parent or specified relative pursuant to a court order or a voluntary placement agreement. This date is related to a child's initial eligibility for title IV-E and is tied to the judicial determinations of contrary to the welfare (or best interest) and reasonable efforts to prevent removal.


  2. Date child entered foster care: Record the date the child is considered to have entered foster care, that is, the earlier of a judicial finding of abuse or neglect or 60 days from the date the child is removed from home. The State may use an earlier date, such as the date the child is physically removed from home. This date is related to maintaining a child's eligibility for title IV-E funding. The State is required to use the date the child is considered to have entered foster care in determining when to obtain the initial judicial determination that it made reasonable efforts to finalize a permanency plan.
C.
Removal Pursuant to a Court Order
  1. Was child's removal the result of a judicial determination? Removal of the child from home must be pursuant to a judicial determination or a voluntary placement agreement. The judicial determination must be made in a valid court order. If the child was not removed pursuant to a court order, enter "no" and proceed to question number 14.


  2. Date of court order removing child from the home: Record the date of the court order that removes the child from home. The date of the court order is required, since Federal financial participation (FFP) cannot begin until the first day of the month in which all eligibility requirements have been satisfied, including a judicial determination that remaining at home is contrary to the welfare of the child.

12a. Contrary to the welfare: The precise language "contrary to the welfare" does not have to be included in the removal court order, but the order must include language to the effect that remaining in the home would be contrary to the child's welfare, safety or best interests. Indicate "yes" or "no."

For a child who enters care prior to March 27, 2000: The judicial determination regarding "contrary to the welfare" must result from court proceedings that are initiated no later than 6 months from the date the child is removed from home, consistent with Departmental Appeals Board (DAB) 1508. If more than 6 months have elapsed and there is no judicial determination, the response to this question is "no" and the child is ineligible for title IV-E for this entire stay in foster care.

For a child who enters care on or after March 27, 2000: The judicial determination regarding "contrary to the welfare" must be made in the first order that sanctions the child's removal from the home, even if the order is an emergency "pick-up" order. The determination must be child-specific and may not merely reference State statutes governing removals. Absent a court order, the only acceptable alternative documentation is a transcript of the court proceedings.

Nunc pro tunc orders and affidavits are not acceptable. If the response to this question is "no," the child is ineligible for title IV-E for this entire stay in foster care.

  1. Is there a court order that addresses reasonable efforts to prevent removal or to reunify child and family? The precise language "reasonable efforts" does not have to be included in the court order, but the order must contain language to the effect that reasonable efforts were made.

    For a child who enters care prior to March 27, 2000: The judicial determination that reasonable efforts were made to prevent removal OR that reasonable efforts were made to reunify the child and family satisfies the reasonable efforts requirement. If both determinations are made, record the date of each determination in items 13a and 13b.

    For a child who enters care on or after March 27, 2000: The judicial determination that reasonable efforts to prevent removal were made or were not required must be made no later than 60 days from the date of the child's removal from home. The determination must be child-specific and may not merely reference State statutes pertaining to removals. Absent a court order, the only acceptable alternative documentation is a transcript of the court proceedings. Nunc pro tunc orders and affidavits are not acceptable.

13a. Record the date of the court order that addresses reasonable efforts to prevent removal.

13b. Record the date of the court order that addresses reasonable efforts to reunify.

D.
Voluntary Placements
  1. Was the child's removal pursuant to a voluntary placement agreement? For title IV-E eligibility purposes, a child must be removed from home pursuant to either a court order or a voluntary placement agreement. Title IV-E payments may be made only on behalf of a child who is in foster care pursuant to a voluntary placement agreement for the first 180 days of the foster care placement, unless there is a judicial determination that continued voluntary placement is in the child's best interests.


  2. Was the voluntary placement agreement signed by parent/legal guardian and the agency representative(s)? A valid voluntary placement agreement must be signed by the parent or legal guardian and the title IV-B/IV-E agency representative(s).

15a. Record the date that the voluntary placement agreement was signed by the parent/legal guardian and the agency representative(s). If signings occurred on different dates, record the date of the final signature. The date that the voluntary placement agreement is signed is required because FFP cannot begin until the first day of the month in which all eligibility requirements have been satisfied. In the case of a child who is voluntarily placed into care, satisfying all eligibility requirements includes a voluntary placement agreement that is signed by the parent or legal guardian and the agency representative.

  1. Is there a judicial determination regarding the child's best interest within 180 days of the date of placement? The State can claim FFP for up to 180 days for a child who is removed pursuant to a voluntary placement agreement in accordance with its State plan. If more than 180 days have elapsed since the date of the child's placement in foster care pursuant to a voluntary placement agreement, there must be a judicial determination to the effect that this placement is in the best interests of the child. If more than 180 days have elapsed and there has been no such determination, the child's eligibility for FFP ceases on the 181st day. If fewer than 180 days have elapsed since the child's date of placement, check "N/A."

16a. Record the date of the judicial determination regarding the child's best interest.

E.
Ongoing Judicial Activity

Disallowances will be taken for any case that does not meet this requirement after March 27, 2001.

  1. Is a judicial determination regarding reasonable efforts to finalize the permanency plan due during the period under review? In order for a child to be eligible for title IV-E payments, there must be a judicial determination that reasonable efforts were made to finalize the child's permanency plan that is in effect, which may include reunification, adoption, legal guardianship, placement with a fit and willing relative, or another planned permanent living arrangement. The date by which a judicial determination of reasonable efforts to finalize the permanency plan must be made is no later than 12 months from the date on which the child is considered to have entered foster care (question number 10) and at least once every 12 months thereafter while the child is in foster care. If a judicial determination regarding reasonable efforts to finalize a permanency plan is not made within this timeframe, the child is ineligible at the end of the 12th month from the date the child was considered to have entered foster care or at the end of the month in which the subsequent judicial determination of reasonable efforts was due, and the child remains ineligible until such a judicial determination is made.

This requirement may also be satisfied by a judicial determination that reasonable efforts were made to reunify child and family. An "N/A" response to this item should be recorded when less than 12 months has elapsed since the date the child is considered to have entered foster care.

17a. If applicable, record the date that the judicial determination was due.

17b. If applicable, record the date of the court order that addressed reasonable efforts to finalize the permanency plan.

17c. Was the court order that addressed reasonable efforts to finalize the permanency plan dated after the due date. If a judicial determination was due during the review period and was not made, the case is in error.

17d. If applicable, indicate the beginning and ending dates that the case is in error. The case is in error at the end of the 12th month from the date the child was considered to have entered foster care or at the end of the month in which the subsequent judicial determination of reasonable efforts was due, and remains in error until a judicial determination that addresses reasonable efforts to finalize the permanency plan is made.

F.
AFDC Eligibility
  1. Date child last lived with parent/specified relative: Record the date the child last lived with the specified relative from whom he or she was removed. A specified relative is defined at 45 CFR 233.90(c)(1)(v). A child may be considered to meet the requirement of living with one of the relatives specified in the Social Security Act if the child is with a parent or person in one of the following groups: (1) any blood relative, including those of half-blood, and including first cousins, nephews, or nieces; persons of preceding generations as denoted by prefixes of grand, great, or great-great; (2) stepfather, stepmother, stepbrother, and stepsister; (3) persons who legally adopt a child or the child's parent as well as the biological and other legally adopted children of such persons, and other relatives of the adoptive parents in accordance with State law; and (4) spouses of any persons named in the above groups, even after the marriage is terminated by death or divorce. See IM-92-04.


  2. Was the child living with the specified relative within 6 months of the initiation of court proceedings or the voluntary placement agreement? The court order removing the child must have been initiated, that is, the petition filed or a voluntary placement agreement signed, no longer than 6 months after the child was living with the specified relative from whom he or she was removed. To be eligible for title IV-E, a child must be eligible for AFDC at home in the month the voluntary placement agreement was signed or the petition was filed. If this is not the case, the statute allows a 6-month period during which the child may reside with an interim caretaker and still be eligible for title IV-E. If more than 6 months have elapsed from the date of the petition and the date child last lived with the specified relative, the child is ineligible for title IV-E. Indicate "yes" or "no."


  3. Was the child living with and removed from the same specified relative? If "no," the child is ineligible for title IV-E. The "living with" and "removal from" requirements have to be satisfied by the same specified relative. Section 472(a)(4)(A) and (B) of the Act requires that the child either: 1) received AFDC in or for the month the voluntary agreement was signed or court proceedings leading to the removal of the child from home were initiated; OR 2) the child would have received AFDC in or for such month if an application had been made, or if he or she was living with the specified relative and would have received AFDC in or for such month if in such month he had been living with "such a relative" (i.e., the same relative) and application had been made. The statute did not contemplate the "living with" and "removal" from requirement to be satisfied by two discrete individuals, but by the same relative.


  4. Eligibility for AFDC at removal: Using its criteria in effect in its July 16, 1996 Title IV-A State plan (OR, IF REMOVAL WAS PRIOR TO THE EFFECTIVE DATE OF THE PERSONAL RESPONSIBILITY AND WORK OPPORTUNITY RECONCILIATION ACT OF 1996 [PRWORA] THE TITLE IV-A STATE PLAN IN EFFECT AT THE TIME), the State must document that the child was removed from a specified relative, and that the child was financially needy and deprived of parental support in the month the voluntary placement agreement was signed or the month in which the petition that resulted in a court-ordered removal was signed. Deprivation must be by reason of death, absence, physical or mental incapacity of one parent, or the unemployment of the principal wage earner. The reviewer is not responsible for making the determination of AFDC eligibility, but for verifying, based on the documentation that is provided, that the State made or did not make the determination. If the child was removed from an "active" AFDC home with an assigned AFDC case number, the reviewer may respond "yes" to this question, record the case number and proceed to question number 22. If the child is not eligible for AFDC, the child is ineligible for title IV-E from the beginning of this placement episode.

21a. Was financial need established? Indicate "yes" or "no."

21b. Was deprivation of parental support or care established? Indicate "yes" or "no."

  1. Was the child's eligibility redetermined? If the child was in care for less than 1 year prior to the period under review, the response to this question is "N/A." For a child in foster care for longer than 1 year, the State must document annually that the child continues to be financially needy and deprived of parental support or care, using the State's criteria in effect in its July 16, 1996, title IV-A State plan. The basis for the determination of financial need is the child in foster care as his/her own assistance unit. The basis for the deprivation of parental support is the home from which the child was removed. If more than 1 year has elapsed and no redetermination was done, the State must reconstruct AFDC eligibility or the child is ineligible for title IV-E.

22a. Record the date of the redetermination.

  1. Does financial need exist throughout the period under review? Using the State's mechanism to document the child's eligibility at redetermination, respond "yes" or "no."

23a. If the response to question number 23 is "no," was title IV-E claimed for the period of ineligibility? If "yes," this case is in error.

  1. Does deprivation exist throughout the period under review? Using the State's mechanism to document the child's eligibility at redetermination, respond "yes" or "no."

24a. If the response to question number 25 is "no," was title IV-E claimed forthe period of ineligibility? If "yes," this case is in error.

G.
State Agency Responsibility for Placement and Care
  1. Agency responsibility for placement/care: The title IV-E agency (or another public agency, including an Indian tribe, with which the title IV-E agency has a written agreement which is in effect) must have responsibility for placement and care of the child. The court order or voluntary placement agreement must indicate that the agency has this responsibility. A response of "yes" to this item indicates that the agency held this responsibility for the entire review period. (Note that the reviewer must verify that the title IV-E agency has a bonafide agreement in effect with the agency for the time period under review in those instances where another public agency has responsibility for placement and care of the child.)


  2. If the response to question number 26 is "no," was title IV-E claimed for the period of ineligibility? If "yes," this child is ineligible.


  3. Name of agency: Record the name of the agency or agencies with responsibility for placement and care of the child during the review period.
H.
Placement in a Licensed Home or Facility

This section is to be completed for each home or facility.

X2-X5. Record provider information for each home or facility in which the child was placed during the period under review.

  1. Child's date of placement in home or facility: Record the date that the child was placed in EACH facility that is included in the period under review.


  2. Date of child's departure from home or facility: Record the date that the child left this facility, if applicable.


  3. Type of foster care facility: The reviewer is to determine if the child is placed in one of the following title IV-E eligible facilities: foster family home, group home, public institution of 25 children or fewer, or private non-profit or for-profit child care institution. A facility that does not fall into one of these categories is not eligible for Federal matching funds. A child placed in facilities such as detention centers, hospitals, and public institutions of more than 25 children are ineligible for title IV-E. The "other" category should be used when the child is not in one of the placements indicated above. If placement is "other," the provider is ineligible.


  4. Licensed or approved facility: The license must show that the home or facility is licensed during the child's placement there. Indicate whether or not the foster care home or facility, regardless of type, was licensed or approved. The terms "licensed" and "approved" are used here to refer to facilities that meet all of the State's standards for full licensure or approval. Full licensure must be met by all providers, including those licensed/approved by a child placing agency, effective September 28, 2000. (No disallowances will be taken from 3/27/00 - 9/27/00 for homes that were licensed prior to 3/27/00 that do not meet full licensure status.)

31a. Period of licensure: Record the dates of the period of licensure or approval of the facility that encompass the period under review.

31b. If the response to question 32 is "no," was title IV-E claimed for the ineligible period? If "yes," this case is in error.

I.
Safety Requirements of Provider

This section is to be completed for each home or facility.

  1. Opt-out provision: Has this State opted out of the criminal records check requirement for foster and adoptive parents? If "yes," proceed to question number 34. If "no," continue to question number 33.


  2. Satisfactory completion of criminal records check: Unless the State has opted out of the criminal records check requirement, the State must provide documentation that criminal records checks have been conducted with respect to prospective foster and adoptive parents. The licensing file must contain documentation of the criminal records checks. A response of "N/A" indicates the child is not placed in a foster family home or a pre-adoptive home.


  3. Safety requirements for foster/adoptive homes when state has opted out of criminal records check: In all cases where the State opts out of the criminal records check requirement, the licensing file for that foster or adoptive family must contain documentation that verifies that safety considerations with respect to the caretaker(s) have been addressed. A response of "N/A" indicates that the child is not placed in a foster family home or a pre-adoptive home OR that the State has not opted out of the criminal records check requirement.


  4. Safety requirements for staff/caretakers in child care institutions: In order for a child care institution to be eligible for title IV-E funding, the licensing file for the institution must contain documentation which verifies that safety considerations with respect to the staff of the institution have been addressed. A response of "N/A" indicates that the child is not placed in a child care institution.

After this checklist is completed, determine if the child is eligible for the entire sample review period and if the provider is eligible for the entire sample review period, and so indicate at the top of this checklist. If the child or provider has any periods of ineligibility during the review period and title IV-E was claimed, the case is in error.

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