Health Report For Foster And Adoptive Parents

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Iowa Department of Human Services
Health Report for Foster and Adoptive Parents
If family members are under the care of separate practitioners, complete a form for each
member. The family should complete Part C before visiting the health practitioner.
A. To the health practitioner:
The family named below plans to give care to children and has been asked to obtain this
statement from their health practitioner. Your assistance in verifying the fact that the family
members are in sound physical and mental health will assist us in completing the study of this
family. Thank you.
Contractor Licensing Worker’s Signature
Father’s Name
Mother’s Name
Children
Street
City
County
State
Zip Code
B. Health practitioner’s statement:
On the basis of my examination of the members of this family, each member is in sound
physical and mental health and there is no evidence of any communicable or infectious
disease which would be detrimental to the well-being of a child placed in this home. The
family’s health would not prevent them from providing needed care to children.
The following problems prevent me from signing the statement above and cause me to
recommend against licensing as a foster family home or approval as an adoptive family.
Health Practitioner’s Signature
Date
470-0720 (Rev. 7/10)
Original: Department
Copy: Retention and Recruitment Contractor

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