Form Soc 818 - Relative Or Non-Relative Extended Family Member Caregiver Assessment Page 2
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6Child’s Name:
Case Number:
Child’s Name:
Case Number:
Caregiver Name: __________________________________________________________________________________
5. The caregiver shall be responsible for applying the Reasonable and Prudent Parent
Standard, which is characterized by careful and sensible parental decisions that shall take in
consideration the age, maturity and developmental level, behavioral tendencies, mental and
physical health, medications, abilities and limitations, the nature and inherent risks of harm, in
order to maintain the child’s health, safety, and best interest. [§89377]
[
] Yes [
] No
Comments:
6. The caregiver will ensure that only positive discipline practices which promote the health and
well being of the child are used in the home, and will not use corporal punishment or allow any
form of discipline that violates the child's personal rights. [§89372(a)(1)]
[
] Yes [
] No
Comments:
7. The caregiver understands and agrees to maintain the child's records, including the
placement agreement, health and educational records, and written consent for
medical/dental treatment. [§89370]
[
] Yes [
] No
Comments:
8. The caregiver agrees to report any accidents, injuries or incidents that threaten to harm the
physical or emotional health or safety of the child within 24 hours after the event occurs by
telephone, e-mail, or fax and submit a written report within 7 calendar days to the approval
agency. [§89361(a) and (b)]
[
] Yes [
] No
Comments:
9. The caregiver agrees to report any change in household composition within 24 hours, and a
change in the residence or mailing address within 10 working days, by telephone, e-mail, or fax
to the approval agency. [§89361]
[
] Yes [
] No
Comments:
SOC 818 (12/10)
Relative or Non-Relative Extended Family Member
Caregiver Assessment
Page 2 of 6
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