Foster And Adoptive Family Home Health Inspection Report printable pdf download

Foster And Adoptive Family Home Health Inspection Report

STATE OF NEW HAMPSHIRE

Form 2360

Department of Health and Human Services

October 2005

Division for Children, Youth, and Families

FOSTER AND ADOPTIVE FAMILY HOME HEALTH INSPECTION REPORT

Date ___/___/_____

Return this form when complete to _______________________ District Office

Address _______________________________________________________

Name of Applicant _________________________________________ Telephone ______________________

Street ___________________________________________________________________________________

Town or City __________________________________________ State _______ Zip Code ______________

HEALTH REQUIREMENTS

YES

Is there hot and cold running water under pressure available for household use?

If water is not from a public supply, has it been tested within the last two years

and are the lab results available?

Is there a functioning sewage disposal system?

Is the home free of evidence of insects and rodents?

Are there sanitary and safe facilities for the storage, preparation, and serving of food,

Including refrigeration and a means for sanitation of utensils?

Are all toxic materials such as cleaners, medicines, household chemicals, and paints

clearly labeled, stored in original containers separate from food and not accessible to

young children

Is the home and yard where young children are cared for, safe from potential

sources of injury? Safety precautions include but are not limited to porch and stair

railings, stove and heater guards, swimming pool fences, locks and covers on wells.

Are pet dogs licensed and do they have current rabies vaccination certificates?

Comments:

Inspected by: __________________________________ for __________________, NH __________________

Signature of Health Officer

Town/City

Telephone

Date of Inspection: ______________

Approved

Not Approved

Signature of Foster Parent ___________________________________________________________

White - DCYF File

Canary - Health Officer

Pink – Foster/Adoptive Parent

PD 05-11

Foster And Adoptive Family Home Health Inspection Report