Health Report For Foster And Adoptive Parents (Page 6 of 6) in pdf

Health Report For Foster And Adoptive Parents Page 6

Iowa Department of Human Services

Provisions for Alternate Water Supply

Assurances from foster family:

I agree to provide safe drinking water to all foster children placed in my home. I also agree to

ensure that foster children drink only safe water. I will obtain safe drinking water from:

(Place/name where supply will be obtained)

This is:

Purchased bottled water

A public water supply

A private water supply (Attach form 470-0693 and water analysis report)

I will use the following storage procedures to ensure that the safe water supply identified

above does not become contaminated (briefly identify gathering and transportation process,

storage containers, length of storage, location of storage, etc.):

I will take the following steps to ensure that foster care children do not drink unsafe water:

In the case of purchased water, I will keep all the receipts for review by the licensing worker.

Signature of Applicant 1

Date

Signature of Applicant 2

Date

Licensing agency agreement:

This above plan is to ensure that any foster care child placed in this home will drink only safe

water. I certify that I have discussed this plan with the foster parents. The foster family

parents have agreed to honor this agreement. I will monitor compliance with this plan when

making visits to the foster home.

Licensing Worker

Date

I approve these conditions.

Signature of Service Area Manager or Designee

Date

470-0699 (Rev. 9/09)

Copy 1: Department

Copy 2: Contractor File

Health Report For Foster And Adoptive Parents Page 6