ࡱ> q` *bjbjqPqP 8:: "HHHHHHH\@4@4@48x4l5\<7 \<(<<<_=E>t><%''''''$hKHE_=_=EEKHH<<`JJJEvH<H<%JE%JJ*HH<07 `@43FR$ v0FH>rg@JoACBz>>>KKaJ^>>>EEEE\\\.@4\\\@4\\\HHHHHH REQUIREMENTS FOR A NEVADA ICPC REFERRAL (FPO-0701C) Include two (2) hard copies (required) and one (1) electronic CD copy (if possible) of all required documents in your referral in the following order. Complete this document, sign and place it after your cover letter. ABCDEF Items that are REQUIRED to process the ICPC referral If the required items are not included, your file will be returned. Please check off each item as required to ensure that your file is complete. (*Private Adoptions, Foster Home Studies, Reg 1, Reg 6, and Reg 7, see special guidelines for additional information)Priority Home Study (Reg 7)*Relative Home StudyFoster Home Study*Adoptive Home StudyResidential Treatment HomeRelocation of Family (Reg 1)*Forms:ICPC 100A - Completed and signed One for each child  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX ICPC 101 completed and signed (only for Reg 7) FORMCHECKBOX Cover Letter:Address to Deputy Compact Administrator ICPC Deputy Compact Administrator ICPC Division of Child and Family Services 4126 Technology Way, 3rd Floor, Carson City, NV 89706 FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Identify child(ren) FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Identify proposed placement Name Address Telephone Number Relationship to child(ren)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Provide Brief Statement of Legal Status FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Provide Reason for Proposed Placement FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Provide Long Term Plan FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Request that all information be forwarded to receiving state. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Explain any special considerations or circumstances regarding the placement, the child(ren) or the request, if not clearly addressed in attachments.  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Court OrdersCustody Court Order - Signed showing agency legal custody of the child(ren). FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX A Reg. 7 or Priority Placement Court Order This court order must be received in the Central ICPC office within five business days of the date of signature.  FORMCHECKBOX Termination of Parental Rights Court Order child must be free. FORMCHECKBOX Documents:Yerington Tribal ROP Sign-off Approval FORMCHECKBOX Financial/medical plan One for each child FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX IV-E Eligibility Documentation explanation of current status FORMCHECKBOX Child/Family Summary/History usually in the initial/dispositional court report and current court report. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Childs Permanency Plan including supplements if applicable FORMCHECKBOX Licenses, certification or approval of qualification - of custodian(s) and/or their home showing status of custodians as qualified. FORMCHECKBOX Home Study - completed/updated appropriate to placement type FORMCHECKBOX First Health - approval FORMCHECKBOX These items are required to be supplied before final approval of placement.Additional Documents:ABCDEFCopy of birth certificate or proof of application FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Copy of social security card or proof of application FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Immunization record FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX School records if child is of school age. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Psychological evaluations, if available. FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Medical records, if available FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Verification of complete Nevada ICPC referral file: _________________________________ _________________________________ Signature of Worker Date Signature of Supervisor Date Additional Information and Instructions Complete this checklist document, sign and place it after your cover letter. Two (2) copies of hard files (required) and one (1) electronic CD copy (if possible) may be mailed to: Nevada ICPC, Division of Child and Family Services, 4126 Technology Way, 3rd Floor, Carson City, NV 89706. Electronic Files: Nevada now scans and forwards all documents electronically to the receiving party when at all possible. Therefore, if you can include an electronic copy on CD we would greatly appreciate it. The extra paper copy requested is being sent in for forwarding purposes to the entities that do not accept scanned requests. You will be copied in the e-mail when we send the documents to the receiving state electronically. Please be sure to print or archive the email when you receive it as we will not be sending paper backup. Incomplete Packets: As of 11/26/2007 we will no longer be able to keep incomplete packets in this office due to the high volume of referrals. Special Guidelines: Private Adoptions: Please complete form FPO-0701D. Foster Home Placements: If you want your placement resource to get paid, you must request a foster home study. If your placement resource is outside the third level of consanguinity you must request a foster home study. Priority Home Studies (Reg 7) The request must be for a relative home study, not foster or adoptive, and the child may not be already placed in the receiving state in violation of ICPC The child must be in an emergency shelter OR be under two years of age OR have spent a considerable amount of time with the proposed placement resource. Relocation of Family Units (Reg 1) 100A and all accompanying information shall clearly state that a relocation of a family unit is involved and that the family home is not yet in the receiving state. Regulation No. 6 (Cited from the Guide to the Interstate Compact on the Placement of Children). Permission to Place Child: Time Limitations, Re-application Permission to place a child given pursuant to Article III (d) of the Interstate Compact on the Placement of Children shall be valid and sufficient to authorize the making of the placement identified in the written document ICPC-100A, by which the permission is given for a period of six (6) months commencing on the date when the receiving state compact administrator or his duly authorized representative signs the aforesaid ICPC-100A. If the placement authorized to be made is not made within the six (6) months allowed therein, the sending agency may reapply. Upon such reapplication, the receiving state may require the updating of documents submitted on the previous application, but shall not require a new home study unless the laws of the receiving state provide that the previously submitted home study is too old to be currently valid. If a foster care license, institutional license or other license, permit or certificate held by the proposed placement recipient is still valid and in force, or if the proposed placement recipient continues to hold an appropriate license, permit or certificate, the receiving state shall not require that a new license, permit or certificate be obtained in order to qualify the proposed placement recipient to receive the child in placement. Upon reapplication by the sending agency, the receiving state shall determine whether the needs or conditions of the child have changed since it initially authorized the placement to be made. The receiving state may deny the placement if it finds that the proposed placement is contrary to the interests of the child.     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