Form Rfa 03 - Resource Family Home Health And Safety Assessment Checklist Page 4
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4Resource Family/Applicant Name: ___________________________________ Family ID Number: _________________
Notes/Comments Continued:
I certify the home of
as of
DATE
meets
does not meet
the home environment assessment standards required for Resource Family Approval,
I
I
excluding the background check.
DATE
AUTHORIZED COUNTY REPRESENTATIVE
By signing below I/we acknowledge that I/we have received a copy of this report.
RESOURCE FAMILY/APPLICANT 1
DATE
RESOURCE FAMILY/APPLICANT 2
DATE
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