Foster And Adoptive Family Home Health Inspection Report (Page 2 of 2) in pdf

Foster And Adoptive Family Home Health Inspection Report Page 2

STATE OF NEW HAMPSHIRE

Form 2360(i)

Department of Health and Human Services

October 2005

Division for Children, Youth, and Families

Instructions to the “Foster and Adoptive Family Home Health Inspection Report”

PURPOSE:

The “Foster and Adoptive Family Home Health Inspection Report” is used to indicate that a foster or adoptive

home being licensed complies with the life safety code for a single family or multi-unit residence prior to

issuance of a license or permit.

INSTRUCTIONS:

Form 2360 is a one-page (form printed on 3-part paper) completed by the local home health inspector after an

inspection of the home. The health inspector retains the second copy, gives the third copy to the foster/adoptive

parents, and returns the original to the local District Office.

FORM COMPLETION:

Enter the current date and the name and address of the District Office.

Enter the name, telephone number, and address of the foster/adoptive family.

The health inspector checks each item with a Yes or No answer. Any questions answered by a “no” response

must be explained in the section for comments below.

If the home meets or exceeds the requirements, the health inspector dates and signs the form and returns it to the

District Office noted.

If the home does not meet the requirements, the health inspector notifies the applicant and recommends changes

or improvements needed.

RETENTION:

Form 2360 is retained indefinitely in the foster/adoptive parent’s record.

PD 05-11

Foster And Adoptive Family Home Health Inspection Report Page 2