Department of Children, Youth & Families

Number Sort descending	Form Name	File Format
	Provider Change Form	English (PDF)
	Provider Direct Deposit Authorization Form	English (PDF)
	State Fiscal Quarterly Report	English (Excel)
	Provider Registration Form	English (PDF)
	File Checklist (Kinship License)	English (Word)
00-002	COVID- 19 Prevention, Intervention and Quarantine Plan	English (Word)
00-005	HVSA Expansion Application Template	English (Word)
00-005A	2022 Spring HVSA Tribal Expansion Funding Application	English (Word)
02-003	Application for Early Learning Advisory Council	English (Word)
02-003a	Application for Provider Supports Subcommittee	English (Word)
02-003b	Parent Advisory Group (PAG) Application	English (Word) Spanish (Word) Spanish (PDF)
02-006	Treatment Foster Care Initiative (TFCI) Referral	English (Word) Treatment Foster Care Initiative (TFCI) Information
02-020	Guide to Background Checks	English (PDF)
02-026	Unsung Hero Nomination Form	English (Word) English (PDF) Somali (Word) Spanish (Word)
02-031	WA State Citizen Review Panels (CRP) Data Request Form	English (Word)
02-206	Statement of Earnings	English (Word) English (PDF) Albanian (PDF) Spanish (PDF)
03-374B	Agreement on Nondisclosure of Confidential Information-Non Employee	English (Word) English (PDF)
03-415	Facility Short Term Use Application	English (Word) English (PDF)
03-492	Foster Parent Recipient Shared Leave	English (Word) English (PDF)
03-493	Foster Parent Donor Shared Leave	English (Word) English (PDF)
04-220	Family Ancestry Chart	English (Word) English (PDF)
04-225	CBCAP Quarterly Report	English (Word)
05-001	Expression of Interest	English (Word) English (PDF) Somali (Word) Somali (PDF) Spanish (Word) Spanish (PDF)
05-002	Funding Organization Commitment	English (Word) English (PDF) Somali (Word) Somali (PDF) Spanish (PDF0 Spanish (Word)
05-003	Provider Application Form	English (Word) English (PDF) Somali (Word) Somali (PDF) Spanish (Word) Spanish (PDF)
05-004	ECEAP Community Funded	English (Word) English (PDF) Somali (Word) Somali (PDF) Spanish (Word) Spanish (PDF)
05-005	Education Appeal	English (Word) English (PDF)
05-006	2022-2023 ECEAP Prescreen and Application Combined Form	English 2022-2023 Combined (PDF) English 2022-2023 Prescreen (PDF) English 2022-2023 Application Spanish 2022-2023 Combined (fillable PDF) Spanish 2022-2023 Prescreen (fillable PDF) Spanish 2022-2023 Application (fillable PDF) Amharic 2022-2023 Combined Application and Prescreen Arabic 2022-2023 Combined Application and Prescreen Russian 2022-2023 Combined Application and Prescreen Ukranian 2022-2023 Combined Application and Prescreen Vietnamese 2022-2023 Combined Application and Prescreen
05-007	ECEAP Contractor Financial Disclosure Certification	English (PDF)
05-008	Early ECEAP Prescreen & Application (Combined Form)	English 2022-2023 Combined (PDF) English 2022-2023 Prescreen (PDF) English 2022-2023 Application (PDF) Spanish 2022-2023 Application (fillable PDF) Spanish 2022-2023 Prescreen (fillable PDF) Spanish 2022-2023 Application (fillable PDF)
05-009	ECEAP Professional Development Plan Assistant Teacher	English (Word) English (PDF)
05-010	ECEAP Professional Development Plan Lead Teacher	English (Word) English (PDF)
05-011	ECEAP Professional Development Plan Family Support Staff	English (Word) English (PDF)
05-012	Approval of New Early ECEAP Site/Classroom	English (Word)
05-021	ECEAP Contractor Alternative Attendance Plan Request	English (Word) English (PDF)
05-022	ECEAP Contract Waiver-Variance Request to ECEAP Requirements	English (Word) English (PDF)
05-023	ECEAP Contractor Purchase Request	English (Word) English (PDF)
05-024	ECEAP Contractor Equipment Disposal Request	English (Word) English (PDF)
05-026A	ECEAP and B-3 Services Application	Exhibit A: ECEAP and B-3 Services Application Exhbit B: Letters of Support and Collaboration Exhibit C: Coordination with Neighboring Head Start/ECEAP and Tribal Organizations (Scored) Exhibit D: Budget Exhibit F: Certifications and Assurances
05-027	ECLIPSE Services Application Packet	Exhibit D: Startup Budget Exhibit E: ECLIPSE Services Application Form Exhibit F: Certifications and Assurances
05-031	Parent Consent to Transfer ELMS Records	English (Word) English (PDF) Spanish (PDF)
05-032	ECEAP Complex Needs Fund (CNF) Grant Application Guidance	English Application Guidance (PDF)
05-034	ECLIPSE RFA Applications and Guides	Request for Application References Budget Form ECLIPSE Request for Application Guide ECLIPSE Minimum Service Delivery Requirements Table
05-041	Licensing Dvisions Practice Change Request Review & Approval	English (Word)
05-041A	Licensing Division Practice Change Request	English (Word)
05-050	Citizen Review Panel Membership Application	English (Word)
05-051	Citizen Review Panel Confidentiality Agreement	English (Word)
05-250	Certification Regarding Environmental Tobacco Smoke	English (Word) English (PDF)
05-305	ADA/504 Discrimination Complaint/Grievance Form	English (PDF)
05-320	2018-19 Financial Disclosure Certification	English (PDF)
05-325	ECEAP Porgram Monitoring Document Review Checklist	English (Word) English (PDF)
06-006	Pinwheel Order Form	English (PDF)
06-097	Provider File Action Request	English (Word) English (PDF)
06-160	Adoption Support Monthly Counseling Billing	English (Word) English (PDF)
06-165	Extended Foster Care (EFC) Denial Letter	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
06-166	Individual Training Plan	English (Word) Spanish (Word) Spanish (PDF)
06-172	Domestic Violence Prevention Account	English (Word) English (PDF)
06-179	Education and Training Voucher (ETV) Spending Plan	English (Excel)
07-085	Client Travel Approval Quick Reference Guide	English (PDF)
07-090 Contact Forms Manager for translation revisions	Caregiver Monthly Transportation Reimbursement	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
07-110	Child Care Stabilization Grant Application – Family, Friend, and Neighbor (FFN) License- Exempt Providers	English (PDF) Somali (fillable PDF) Spanish (fillable PDF)
07-110A	Child Care Stabilization Grant Spend Period Extension Request	English (Word) Somali (PDF) Spanish (PDF) Spanish (Word)
07-110B	Stabilization Grant Receipt Verification Form Program and Add-On Amounts	English (Word) Somali (PDF) Spanish (Word) Spanish (PDF)
07-110C	Stabilization Grant Receipt Verification Form Workforce Amounts	English (Word) Somali (PDF) Spanish (Word) Spanish (PDF)
07-112	Spring 2021 Child Care COVID -19 Grant Receipt Verification	English (Word) Somali (PDF) Spanish (PDF) Spanish (Word)
07-112a	Early Achievers Needs-Based Grant Receipt Verification Form	English (Word) Somali (PDF) Spanish (Word) Spanish (PDF)
08-050	Request/Certification of Data Destruction	English (Word) English (PDF)
09-007	Petition for Review of Initial Decision (Appeal)	English (Word) English (PDF)
09-010	Child Welfare History	English (Word)
09-012	Request for Certificate of Parental Improvement (CPI)	English (Word) English (PDF)
09-013	Vendor Affidavit of Lost, Stolen or Destroyed Warrant	English (Word) English (PDF)
09-026	DSO & Jail Removal Data Form	English (Word)
09-031	Authorization By Subject of Records Requested	English (Word) English (PDF)
09-054	Waiver of Notice of Further Hearing	English (Word) English (PDF)
09-056	Dependent/Ward of the Court Verification	English (Word) English (PDF)
09-082	Five Day Notification to Move	English (Word) English (PDF)
09-093	School Notification	English (Word) English (PDF)
09-095	Court Report	English (Word) English (PDF)
09-100	Hiring Education Affidavit Request (Early Learning)	English (Word) English (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
09-101	Hiring Education Affidavit Request (School Age)	English (Word) English (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
09-102	Hiring Education Affidavit Request (Outdoor Nature-Based)	English (Word) English (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
09-104	ICPC Closure Letter	English (Word) English (PDF)
09-111	Continuous Quality Improvement Confidentiality Agreement	English (Word) English (PDF)
09-126	Local Indian Child Welfare Advisory Committee Confidentiality Agreement	English (Word) English (PDF)
09-127	Rights of Children and Youth in Foster Care	English (Word) English (PDF)
09-128	Child Fatality Case Review Confidentiality Agreement	English (Word) English (PDF)
09-129	Child Near Fatality Case Review Confidentiality Agreement	English (Word) English (PDF)
09-131	Background Check Request/Decision	English (Word) English (PDF) Marshallese (PDF) Spanish (Word) Spanish (PDF)
09-132	Employee Background Check Request/Summary	English (Word) English (PDF)
09-154	NCIC Purpose Code C Background Check Summary	English (Word) English (PDF)
09-160	Background Check Hearing Request Form	English (Word) English (PDF)
09-162	Background Check Reconsideration Request	English (Word) English (PDF)
09-164	Request for Early Learning Background Check Results	English (Word) English (Word) Somali (fillable PDF) Spanish (fillable PDF)
09-165	Portable Background Check Application	English (PDF)
09-539	Inquiry to Indian Tribe	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
09-611	Release and Consent for Child Specific Recruitment	English (Word) English (PDF)
09-653	Background Check Authorization	English (Word) English (PDF) Cambodian (PDF) Chinese (PDF) Chinese (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Vietnamese (PDF)
09-761	Indian Identity Request	English (Word) English (PDF)
09-765	Declaration of Adoption Facilitator - Indian Child	English (Word) English (PDF)
09-837	Disclosure of Confidential HIV / AIDS Information	English (Word) English (PDF)
09-966	Authorization to Release Information to the Court	English (Word) English (PDF)
09-979	Marital/Domestic Partnership History	English (Word)
09-997	Adoption Support Worksheet	English (Word) English (PDF) Vietnamese (PDF)
09-998	Application for the Adoption Support Program and/or Reimbursement of Adoption Finalization Costs	English (Word) English (PDF) Vietnamese (PDF)
10-016	File Checklist and Certification for License of Foster Home	English (Word)
10-017	Termination of Foster Home License	English (Word) English (PDF)
10-042	Child Protective Services Casework Checklist	English (Word) English (PDF)
10-043	Home Study	English (Word)
10-061	Child’s Registration	English (Word) English (PDF)
10-082	Adoption Support Agreement Review	English (Word) English (PDF) Spanish (PDF) Spanish (Word)
10-083	Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Assessment	English (Word) English (PDF)
10-114	Adoption Data Card	English (Word) English (PDF)
10-166A	Behavioral Rehabilitation (BRS) Referral	English (Word) English (PDF)
10-182	File Checklist (Forster License)	English (Word)
10-182A	File Checklist (Unlicensed)	English (Word) Spanish (Word) Spanish (PDF)
10-182B	File Checklist (Provisional Expedited License)	English (Word)
10-183	Home Inspection Checklist (Licensed)	English (Word) Spanish (Word) Spanish (PDF)
10-214	Pre-Authorization For Services	English (Word) English (PDF)
10-248	Compliance Agreement	English (Word) Spanish (PDF) Spanish (Word)
10-248A	Compliance Agreement Continuation	English (Word) English (PDF)
10-261	Foster Care Rate Assessment	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
10-290	WAC Agreements	English (Word) Marshallese (PDF) Somali (PDF) Spanish (Word) Spanish (PDF) Vietnamese (PDF)
10-354	Home Study or Reassessment Application	English (Word) Oromo (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
10-395	Intensive Family Service Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary	English (Word) English (PDF)
10-405	Foster Home Reassessment	English (Word)
10-406	Employed Foster Parent Child Care Plan	English (Word) English (PDF)
10-408	Application for Child Care Agency License or Certification	English (Word) English (PDF)
10-416	Foster Home Monitoring Visit	English (Word)
10-419	Supervision Plan for Site Specific Conditions	English (Word) Spanish (PDF)
10-425	Reference Questionnaire (Certified Respite)	English (Word) Spanish (Word) Spanish (PDF)
10-428	Caregiver Support Plan	English (Word) English (PDF)
10-429	New License Letter	English (Word) Spanish (Word) Russian (Word) Russian (PDF) Somali (Word) Somali (PDF) Spanish (PDF)
10-432	Extended Foster Care Program Participation Agreement	English (Word) English (PDF) Mam (PDF) Spanish (Word) Spanish (PDF)
10-453	Home Inspection Checklist (Unlicensed)	English (Word)
10-454	DCYF Caregiver Authorization	English (PDF) Laotian (PDF)
10-455	Medication Log	English (Word) English (PDF)
10-458	Home Study Referral Notice	English (Word) English (PDF)
10-459	Courtesy Supervision Referral	English (Word) English (PDF)
10-460	Treehouse Educational Advocacy Referral	English (Word) English (PDF)
10-462	User Application and Acknowledgement	English (Word) English (PDF)
10-463	FamLink Data Access Request / Change	English (Word) English (PDF)
10-464	FamLink Access Application and Acknowledgement	English (Word) English (PDF)
10-474	FAR Family Assessment	English (Word) English (PDF) Spanish (Word) Spanish (PDF) Cambodian (PDF) Korean (PDF) Russian (PDF) Somali (PDF) Vietnamese (PDF)
10-475	Early Invention Program (EIP) Exit Summary	English (Word) English (PDF)
10-477	Adoption Support Program Application Checklist	English (Word) English (PDF)
10-479	Early Intervention Program (EIP) 90 Day Review	English (Word) English (PDF)
10-479	Early Intervention Program (EIP) 90 Day Review	English (Word) English (PDF)
10-480	Comprehensive Family Evaluation	English (Word) English (PDF)
10-484	Youth Run Prevention Plan	English (Word) English (PDF)
10-490	Child Specific Contract or Extra Supervision Rate Proposal	English Excel
10-500	Acknowledgement of Child(ren)’s Adoptive File Provided to Adoptive Family:	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
10-507	Orientation Sign-In Sheet	English (Word) English (PDF)
10-537	Interstate Compact for the Placement of Children (ICPC) Parent Home Study Information	10-537 10-537 Spanish (PDF) Spanish (Word)
10-539	Interstate Compact for the Placement of Children (ICPC) Reference Questionnaire for Parent Home Study	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
10-540	Project SafeCare Monthly Summary	English (Word) English (PDF)
10-545	Family Feedback Questionnaire	English (Word) English (PDF)
10-546	Adoption Archive Request for Non-Identifying Information	English (Word) English (PDF)
10-547	Adoption Support Limitations Letter	English (Word) English (PDF) Somali (PDF) Vietnamese (PDF)
10-566	Contracted Health and Safety Visit Referral	English (Word) English (PDF)
10-567	Contracted Health and Safety Visit Report	English (Word) English (PDF)
10-578	Licensing Application Checklist	English (Word) English (PDF) Amharic (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Spanish (Word)
10-581	Unlicensed Placement Application Checklist	English (Word) English (PDF) Spanish (PDF) Spanish (Word)
10-606	Adoptive Parent Counseling Preauthorization for Services	English (Word) English (PDF)
10-650	ESIT Authorization for Release of Records	English (PDF) Amharic (PDF) Arabic (PDF) Chinese (PDF) Farsi (PDF) Khmer (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Urdu (PDF) Vietnamese (PDF)
11-010	Funding Opportunity: Perinatal Mental Health Community Capacity Building	English (Word) English (PDF)
11-011	2022 Spring HVSA Expansion Funding Opportunity Letter of Intent to Apply	English (Word)
11-011A	HVSA Tribal Home Visiting Funding Opportunity Letter of Intent	English (Word)
11-013	Community Based Child Abuse Prevention (CBCAP) Funding Opportunity	English (Word)
11-014	Family Resource Center Capacity Building Funding Opportunity	English (Word)
11-015	CBCAP Returning Programs	English (Word)
11-016	Perinatal Mental Health Year-End Community Report Template	English (Word)
11-017	Diaper Bank Partnership Quarterly Report Form	English (Word)
11-018	Perinatal Mental Health Returning Program	English (Word)
11-019	Diaper Bank Concrete Good for Families Quarterly Report Form	English (Word)
11-020	Tribal Fatherhood Support Program Funding Opportunity	English (Word)
11-021	HV-BAT Supplemental Form	English (Word)
11-022	Family Resource Center Capacity Building Work Plan	English (Word)
11-023	FRC Quarterly Report Form	English (Word)
11-024	Tribal Fatherhood Supports Plan	English (Word)
11-025	Option 1A	English (Excel)
11-026	Option 1B	English (Excel)
11-027	Option 2	English (Excel)
11-028	Tribal Fatherhood Quarterly Reports	English (Word)
12-001	Special Needs Child Care Rate Request	English (Word) English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Dari (PDF) Farsi (PDF) French (PDF) Korean (PDF) Pashtu (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tigrigna (PDF) Urdu (PDF) Vietnamese (PDF)
13-001	Applicant Medical Report- Confidential	English (Word) Oromo (PDF) Spanish (Word) Spanish (PDF) Somali (PDF) Tagalog (PDF) Vietnamese (PDF)
13-001A	Applicant Medical Self Report	English (Word) Marshallese (PDF) Oromo (PDF) Somali (PDF) Spanish (Word) Spanish (PDF) Vietnamese (PDF)
13-001B	Applicant Mental Health Report	English (Word) Spanish (PDF)
13-041	Child's Medical and Family Background Report	English (Word) English (PDF) Cambodian (PDF) Somali (PDF) Spanish (Word) Spanish (PDF) Russian (PDF)
13-904	Diabetes Care and Action Plan	English (Word) English (PDF)
13-907	Brief Assessment of Anxiety and PTSD: Caregiver/Parent	English (Word) English (PDF) Russian (PDF) Somali (PDF) Spanish (PDF)
14-001	Employment Verification for State Training	English (Word) English (PDF)
14-002	Trainer Observation Rubric	English (Word) English (PDF)
14-003	Trainer Observation Rubric (Self Paced)	English (Word)
14-005	OJJDP Title II Pass Through Fund	English (Word)
14-011	Enrollment Application Medical and Dental Benefits	English (PDF) If using chrome, save form to desktop before filling in form Somali (PDF) Spanish (PDF)
14-011a	Change Form Medical and Dental Benefits	English (PDF) Spanish (fillable PDF) Somali (fillable PDF)
14-012	Consent	English (Word) Marshallese (PDF) Spanish (Word) Spanish (PDF) Swahili (PDF)
14-252	Employment Verification	English (Word) English (PDF) Albanian (PDF) Amharic (PDF) Cambodian (PDF) Chinese (PDF) Dar (PDF) Farsi (PDF) French (PDF) Korean (PDF) Lingala (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Swahili (PDF) Tagalog (PDF) Turkish (PDF) Ukaranian (PDF) Vietnamese (PDF)
14-255	Early Childhood Equity Grant Application	English (Word) Arabic (PDF) Chinese (PDF) Russian (PDF) Somali (Word) Spanish (Word)
14-281	Source of Funds Application for Child in Placement	English (Word) English (PDF)
14-293	Title IV-E Initial Eligibility Determination Income Calculation Worksheet	English (Word) English (PDF)
14-319	IV-E Eligibility Determination for an Adoption Support Application	English (Word) English (PDF)
14-319A	IV-E Eligibility Determination For R-GAP, Relative Guardianship Assistance Program	English (Word) English (PDF)
14-417	CCSP Application	Chinese (PDF) Korean (PDF) Pashtu (PDF) Somali (PDF) Spanish (PDF) Spanish (Word) Vietnamese (PDF)
14-417A	Family, Friend, and Neighbor (FFN) In-Home/Relative Pending Letter	English (Word) Amharic (PDF) Dari (PDF) Oromo (PDF) Russian (PDF) Spanish (Word) Spanish (PDF) Ukranian (PDF)
14-434	Title IV-E Requirements for Out of State Foster Care Payments	English (Word) English (PDF)
14-435	Provider Employment Eligibility Verification	English (Word) English (PDF)
14-438	Stop Work	English (Word) Arabic (PDF) Dari (PDF) Oromo (PDF) Somali (PDF) Spanish (Word) Spanish (PDF) Tigrigna (PDF) Vietnamese (PDF)
14-444	Child Health and Education Tracking Screening Report	English (Word) Mam (PDF) Marshallese (PDF) Spanish (Word) Spanish (PDF)
14-446	Declaration of Financial Status for Adoption Support Application	English (Word) English (PDF)
14-452	Financial Worksheet	English (Word) English (PDF) Marshallese (PDF) Oromo (PDF) Spanish (Word) Spanish (PDF) Somali (PDF) Tagalog (PDF) Vietnamese (PDF)
14-474	Shared Planning Meeting	English (Word) Spanish (Word) Spanish (PDF) Cambodian (PDF) Chinese (PDF) Korean (PDF) Mandinka (PDF) Russian (PDF) Somali (PDF) Swahili (PDF) Thai (PDF) Tigrinya (PDF) Trukese (PDF) Vietnamese (PDF)
14-510	Certified Respite Provider Agreements	English (Word) English (PDF) Spanish (PDF) Spanish (Word)
14-512	Application for Certified Respite Provider	English (Word) English (PDF) Spanish (Word) Spanish (fillable PDF)
14-531	Education and Training Voucher (ETV) Program and Passport to Careers Program 2023 – 2024 Application	English (Word) English (PDF)
14-531A	Education and Training Voucher (ETV) Program and Passport to Careers Program Application Consent	English (Word) English (PDF)
14-545	Extended Adoption Support Application	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
14-548	Independent (IL) / Transitional Living (TL) Grant Application	English (Word) English (PDF)
14-600	Interim Individualized Family Service Plans (IFSP) (ESIT)	English (Word)
15-005	ESIT Health Care Referral Form	English (Word) English (PDF)
15-015	Child Care Subsidy Program Site Change Form	English (Word) English (PDF)
15-016	HVSA Local Implementing Agency Contact Update Form	English (Word) English (PDF)
15-025	ESIT COVID-19 IFSP Review Form	English (Word) English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (fillable PDF) Chinese (fillable PDF) Farsi (PDF) Korean (fillable PDF) Laotian (fillable PDF) Punjabi (fillable PDF) Russian (fillable PDF) Somali (fillable PDF) Spanish (fillable PDF) Telugu (fillable PDF) Tamil (fillable PDF) Urdu (PDF) Vietnamese (fillable PDF)
15-027	Professional Services Referral	English (Word) English (PDF) Kanjobal (PDF)
15-028	Psychological Services Referral	English (Word) English (PDF)
15-029	Psychiatric Services Referral	English (Word) English (PDF)
15-030	SUS Residential Referral Form	English (Word) English (PDF)
15-050	Confirmation of Individualized Family Service Plan (IFSP) Schedule	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Urdu (PDF) Vietnamese (PDF)
15-051	Declining One or More Early Intervention Services	English Amharic (PDF) Arabic Cambodian Chinese Farsi Korean Laotian Punjabi (PDF) Russian Somali Spanish Tamil Telugu (PDF) Ukrainian (PDF) Urdu Vietnamese
15-052	Declining Participation in the ESIT Program	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Ukrainian (PDF) Urdu (PDF) Vietnamese (PDF)
15-053	Formal Dispute Resolution Request	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) French (PDF) Korean (PDF) Laotian (PDF) Marshallese (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Urdu (PDF) Vietnamese (PDF)
15-054	Notice and Consent for Evaluation/Assessment	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Ukranian (PDF) Urdu (PDF) Vietnamese (PDF)
15-055	Individualized Family Service Plan (IFSP)	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Telugu (PDF) Tamil (PDF) Urdu (PDF) Vietnamese (PDF)
15-056	Notice of Consent for Initial Evaluation Assessment	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) French (PDF) Korean (PDF) Laotian (PDF) Mashallese (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telegu (PDF) Ukranian (PDF) Urdu (PDF) Vietnamese (PDF)
15-057	Notice and Consent for Screening	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Urdu (PDF) Vietnamese (PDF)
15-058	Parent Prior Written Notice	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Ukrainian (PDF) Urdu (PDF) Vietnamese (PDF)
15-059	Prior Written Notice Consent and Financial Information Forms	English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Laotian (PDF) Punjabi (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tamil (PDF) Telugu (PDF) Ukrainian (PDF) Urdu (PDF) Vietnamese
15-060	Adoption Purchase of Services Contracted Out of State Health and Safety Visit Report	English (Word)
15-092	The Interstate Compact on the Placement of Children (ICPC) Placement Request	English (Word) English (PDF)
15-093	Interstate Compact on the Placement of Children (ICPC) Report on Child’s Placement Date or Change of Placement – 100B	English (Word) English (PDF)
15-128	Verification of Indian Status: Foster Care and Adoptive Applicant	English (Word) English (PDF) Marshallese (PDF)
15-209A	Health/Mental Health and Education Summary	English (Word) English (PDF)
15-209C	Visit Plan	English (Word) English (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Tagalog (PDF) Tigrigna (PDF) Ukrainian (PDF) Vietnamese (PDF)
15-245	LIMITED ENGLISH PROFICIENT (LEP)/DEAF CLIENT SERVICES LEP Client Service Record	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
15-258	Safety Assessment/Safety Plan	English (Word) Russian (PDF)
15-259	Safety Plan	English (Word) English (PDF) Spanish (Word) Spanish (PDF) Amharic (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Punjabi (PDF) Russian (PDF) Somali PDF) Tagalog (PDF) Tigrigna (PDF) Ukrainian (PDF) Vietnamese (PDF)
15-259A	Case Plan	English (Word) English (PDF) Chinese (PDF) Korean (PDF) Russian (PDF) Somali (PDF) Spanish (Word) Spanish (PDF) Vietnamese (PDF)
15-260	Parents Information Sheet for Shared Planning Meetings and Staffings	English (Word) English (PDF)
15-266	Child Protect Teams (CPT) Staffing Recommendations	English (Word) English (PDF)
15-267	Attendance and Confidentiality Agreement	English (Word) English (PDF) Vietnamese (PDF)
15-268	Child Protect Teams (CPT) Case Presentation Summary	English (Word) English (PDF)
15-276	Personal Information	English (WORD) Somali (PDF) Spanish (PDF) Spanish (Word) Tagalog (PDF)
15-280	Unlicensed Caregiver Placement Checklist	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
15-281	Placement Agreement	English (PDF) Contact forms manager for translation revisions as of 3/8/2021 Spanish(PDF) if using Chrome download to desktop to fill out form
15-286	Reference Questionnaire	English (Word) English (PDF) Arabic (PDF) Marhsallese (PDF) Spanish (Word) Spanish (PDF) Tagalog (PDF)
15-286A	Adult Child Reference Questionnaire	English (Word) English (PDF) Arabic (PDF) Marshallese (PDF) Spanish (PDF) Tagalog (PDF)
15-300	Child Information and Placement Referral	English (Word) English (PDF)
15-308	Missing Child Staffing	English (Word) English (PDF)
15-309	Returning Child De-Briefing	English (Word) English (PDF)
15-313	Caregiver’s Report to the Court	English (Word) English (PDF) Spanish (PDF)
15-322	Long Term Care Agreement for Foster Parents or Relative Caregivers	English (Word) English (PDF)
15-324	Guardianship Approval Checklist	English (Word)
15-359	Child's Physical Description	English (Word) English (PDF)
15-362	Concurrent TANF Benefits/Family Reunification Notice of Removal from TANF Home	English (Word) English (PDF)
15-363B	Provider Notification of Visit/Transport Schedule Initial Intake Screening Report	English (Word) English (PDF)
15-363C	Visit Coordination Plan	English (Word) English (PDF)
15-368	Education and Training Voucher (ETV) Program Participation Agreement	English (Word) English (PDF)
15-368A	Education and Training Voucher (ETV) Program Dual Credit Participation Agreement	English (PDF) English (Word)
15-369	Education and Training Voucher (ETV) Program 2023 - 2024 Renewal Application	English (Word) English (PDF)
15-370	Education and Training Voucher (ETV) Program Payment Request	English (Word) English (PDF)
15-372	Enumeration Referral	English (Word) English (PDF)
15-377	Education and Training Voucher (ETV) Program Dual Credit Application	English (Word)
15-402	Notice to Foreign Consulate of Child Protection Proceedings	English (Word) English (PDF)
15-411	Licensing Waiver/Administrative Approval/Relative Non-Safety Exemption	English (Word) English (PDF)
15-411A	Licensing Waiver (Foster Home)	English (Word)
15-411D	Administrative Approval (Foster Home)	English (Word)
15-412	Request for Extension and Disability Verification for Youth Over Age 18	English (Word) English (PDF)
15-416	Interstate Compact for Adoption Medical Assstance ICAMA	English (Word)
15-417	Transition Plan for Youth Exiting Care	English (Word) English (PDF)
15-425	Adoption Redaction Request	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
15-428	Protective Action Plan	English (Word) English (PDF) Spanish (Word) Spanish (PDF) Cambodian (PDF) Chinese (PDF) Korean (PDF) Russian (PDF) Somali (PDF) Vietnamese (PDF)
15-431	Extended Foster Care Program Voluntary Placement Agreement (VPA)	English (Word) English (PDF) Dari (PDF) Spanish (PDF) Spanish (Word)
15-433	Incomplete Application	English (Word) Russian (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
15-433A	Provisional Expedited Incomplete Application	English (Word)
15-434	On-Going Mental Health (OMH) Screening Report	English (Word)
15-448	Family Time Report	English (Word)
15-448A	Supported Visit Report	English (Word) English (PDF)
15-450	Child Specific Caregiver Notification	English (Word) English (PDF)
15-451	Missed and No Show Report: Parent – Child Visit	English (Word) English (PDF)
15-452	Sibling Visit Report	English (Word) English (PDF)
15-454	Unusual Incident Report	English (Word)
15-455	Vaccine Exemption	English (Word) English (PDF) Spanish (Word) Spanish (fillable PDF)
15-460	Background Confirmation and Out of State Check	English (Word) Farsi (PDF) Spanish (PDF) Spanish (Word) Russian (PDF)
15-466	Contract Risk Assessment / Analysis	English (PDF)
15-469	Pre-Contract Action Request (P-CAR)	English (Word) English (PDF)
15-470	DCYF Regional Contract Request	English (Word) English (PDF)
15-472	After-the-Fact Contract Justification	English (Word)
15-491	Plan of Safe Care	English (Word) English (PDF) Arabic (PDF) Cambodian (PDF) Chinese (PDF) Korean (PDF) Laotian (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Vietnamese (PDF)
15-705	FFN Waiver Request	English (Word) Spanish (Word) Spanish (PDF)
15-707	School-Age Child Care Monitoring Checklist	English (Word) English (PDF)
15-708	Child Care Center Monitoring Checklist (Example)	English (Word)
15-709	Family Home Child Care Monitoring Checklist (Example)	English (Word)
15-720	Interest Survey for Organization License Pilot	English (Word) English (PDF) Somali (fillable PDF) Spanish (fillable PDF)
15-820	Tuberculosis (TB) Screening LD	English (Word) English (PDF) Marshallese (PDF) Spanish (PDF) Vietnamese (PDF)
15-821	Infant Safety Agreement	English (Word) Somali (PDF) Spanish (Word) Spanish (PDF) Vietnamese (PDF)
15-821a	Infant Safety Certified Respite	English (Word)
15-822	Influenza Vaccination Agreement	English (Word) Somali (PDF) Spanish (Word) Vietnamese (PDF)
15-822a	Vaccine Agreements Certified Respite	English (Word) English (Word) Spanish (Word) Spanish (fillable PDF)
15-823	Pertussis Vaccination Agreement	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
15-824	Authorization and Consent to Share Records	English (Word) Spanish (Word) Spanish (PDF)
15-824A	Authorization and Consent to Share Records (CPA Home)	English (Word)
15-852	Plan to Meet Experience Qualification	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-853	Intent to Transfer License or Certification	English (Word) English (PDF) Somali (Word) Somali (fillable PDF) Spanish (Word) Spanish (fillable PDF)
15-857	Parent/Provider Health Safety Agreement (FFN)	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-858	Emergency Contact and Permission Form (FFN)	English (Word) Somali (fillable PDF) Spanish (fillable PDF)
15-859	Safety Record and Evacuation Plan	English (Word) English (PDF) Somali (fillable PDF) Spanish (fillable PDF)
15-860	Medication Permission Form For Illness and Allergies (FFN)	English (Word) Somali (fillable PDF) Spanish (fillable PDF)
15-861	Initial Checklist for Child Care Center Applicant	English (Word)
15-862	Initial Checklist for Family Home Child Care Applicant	English (Word)
15-863	Initial Checklist for School-Age Program Applicant	English (Word)
15-874	Capacity Increase Change Planning Guide	English (Word) English (PDF)
15-879	Child Care Registration	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-891	Chimney, Fireplace, Woodstove Use Statement	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-892	Fire, Safety, Emergency Drills Record	English (Word) Somali (PDF) Spanish (PDF)
15-894	Family Home Child Care Liability Insurance Form	Engllish (Word) English (PDF) Somali (PDF) Spanish PDF)
15-895	Overnight Child Care Planning Guide	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-896	Probation Notification Letter to Parents from Provider	English (Word)
15-897	Child Care Parent Guardian Permissions	English (Word) English (PDF) Somali (Word) Spanish (Word)
15-899	Child Licensee or Assistant Resume	English (Word) English PDF) Somali (PDF)
15-937	Child Care Center School-Age Background Checklist	English (Word) English (PDF) Somali (fillable PDF) Spanish (fillable PDF)
15-939	Hearing Request	English (Word) English (PDF) Somali (PDF)
15-941	Child Care Injury Incident Report	Engllish (Word) English (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
15-942	Daily Child Attendance Records	English (Word) English (PDF) Somali (PDF)
15-943	Child Care Agreement	English (Word) Spanish (Word)
15-945	Tribal Certification Request	English (Word)
15-949	Family Home Child Care Background Checklist	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-952	Notification to Parents and Guardian - Safe Sleep Non-Compliance	English (W0rd) English (PDF) Somalie (PDF) Spanish (PDF)
15-954	Notification of Staffing Plan Absence	English (Word) Somali (PDF) Spanish (PDF)
15-955	Family Home and Center Child Care License or Certification Application	English (Word) English (PDF) Somali (PDF) Spanish (PDF) Spanish (Word)
15-956	No Social Security Card Declaration	English (Word) Somali (PDF) Spanish (PDF)
15-957	Child Care Variance Request	English (Word) Somali (PDF) Spanish (PDF)
15-961	Child Care Waiver Request	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-963	Early Learning-Child Care Facility Feasibility Checklist	English (Word)
15-964	Early Learning-Child Care Facility Feasibility Checklist (sa)	English (Word)
15-965	Sanitizer Disinfectant Approval Request	English (Word) Somali (PDF) Spanish (PDF) Spanish (Word)
15-966	Child Care Health Consultant Agreement	Engllish (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-967	Child Care Health Consultant Onsite Report	English (Word) Engllish (PDF) Somali (PDF) Spanish (PDF)
15-968	Child Care Medication Authorization	English (Word) English (PDF) Somali (PDF) Spanish (PDF)
15-969	Child Care Medication Log	Englislh (Word) Somali (PDF) Spanish (PDF)
15-970	Individual Care Plan for Child in Child Care	English (Word) English (PDF) Spanish (PDF)
15-974	Declaration of Compliance	English (Word) English (PDF) Somali (fillable PDF) Spanish (fillable PDF)
15-980	School Age License Application	English (PDF)
16-005	Electronice Attendance Provider Welcome Letter (Barcode)	English (Word) English (PDF)
16-010	Parental Advisory Group (PAG) Cover Letter and Application	English (Word) Somali (fillable PDF) Spanish (fillable PDF) Spanish (Word)
16-015	State Approved Training Concern Form	English (Word) English (PDF)
16-025	Contractor Certification	English (Word)
16-030	Book Review Worksheet for Foster Parent Training Hours	English (Word) Spanish (Word) Spanish (PDF)
16-179	Reference Questionnaire Request	English (Word) English (PDF) Arabic (PDF) Spanish (Word) Spanish (PDF)
16-204	Emergency and Evacuation Plan	English (Word)
16-209	Archived Records Memo Adoption and/or Legally Free Children Aged Out	English (Word) English (PDF)
16-211	Licensing Division (LD) Agency Letter of Reference	English (Word) English (PDF)
16-217	Washington State ICPC Quarterly Supervision Report	English (Word) English (PDF)
16-225	File Checklist (Certified Respite)	English (Word) Spanish (Word) Spanish (PDF)
16-235	Media Release	English (PDF)
17-041A	Request for DCYF Records	English (Word) Russian (PDF) Somali (PDF) Spanish (Word) Spanish (PDF)
17-063	Written Authorization	English (Word) English (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Spanish (Word)
17-215	DCYF Checklist: Subcontractor Approval Request	English (Word) English (PDF)
17-215A	DCYF Checklist: Subcontractor Approval Request	English (Word) English (PDF)
17-251	FERPA Access Request	English (Word) English (PDF)
18-400	Foster Reimbursement Claim	English (Word) English (PDF) Spanish (Word) Spanish (PDF)
18-400A	Third Party Claim Checklist	English (Word) English (PDF)
20-015	Juvenile Rehabilitation Youth Engagement Request	English (Word)
20-016	JR Marriage Approval for Release of Information	English (Word) English (PDF)
20-017	JR Marriage Application	English (Word) English (PDF)
20-020	Acknowledgement of JR Policy 6.70 Marriage in JR Facilities	English (Word) English (PDF)
23-005	Three-Pronged Approach (TPA) I. Parent Inerview Questions Related to Vision and Hearing	English (PDF) Amharic (fillable PDF) Arabic (fillable PDF) Bengali (fillable PDF) Cambodian (fillable PDF) Chinese Simplified (fillable PDF) Chinese Traditional (fillable PDF) Dari (fillable PDF) Farsi (fillable PDF) French (fillable PDF) Hindi (fillable PDF) Japanese (fillable PDF) Kannada (PDF) Korean (fillable PDF) Marshallese (PDF) Nepali (fillable PDF) Pashtu (fillable PDF) Portuguese (fillable PDF) Punjabi (fillable PDF) Russian (fillable PDF) Somali (fillable PDF) Spanish (fillable PDF) Tagalog (fillable PDF) Telugu (fillable PDF) Tigrigna (fillable PDF) Tamil (fillable PDF) Vietnamese (fillable PDF)
23-006	Three Pronged Approach (TPA) II. Developmental Skills Checklist Related to Vision and Hearing in Young Children	English (Word) English (PDF) Amharic (fillable PDF) Arabic (fillable PDF) Bengali (fillable PDF) Cambodian (fillable PDF) Chinese Simplified (fillable PDF) Chinese Traditional (fillable PDF) Dari (fillable PDF) Farsi (fillable PDF) French (fillable PDF) Hindi (fillable PDF) Japanese (fillable PDF) Kannada (PDF) Korean (fillable PDF) Marhsallese (fillable PDF) Nepali (fillable PDF) Pashtu (fillable PDF) Portuguese (fillable PDF) Punjabi (fillable PDF) Russian (fillable PDF) Somali (fillable PDF) Spanish (fillable PDF) Tagalog (fillable PDF) Telugu (fillable PDF) Tigrigna (fillable PDF) Tamil (fillable PDF) Vietnamese (fillable PDF)
23-007	Three-Pronged Approach (TPA) Summary Form Addressing Vision and Hearing Concerns	English (Word) English (PDF) Amharic (fillable PDF) Arabic (fillable PDF) Bengali (fillable PDF) Cambodian (fillable PDF) Chinese Simplified (fillable PDF) Chinese Traditional (fillable PDF) Dari (fillable PDF) Farsi (fillable PDF) French (fillable PDF) Hindi (fillable PDF) Japanese (fillable PDF) Kannada (PDF) Korean (fillable PDF) Marhsallese (fillable PDF) Nepali (fillable PDF) Pashtu (fillable PDF) Portuguese (fillable PDF) Punjabi (fillable PDF) Russian (fillable PDF) Somali (fillable PDF) Spanish (fillable PDF) Tagalog (fillable PDF) Tigringa (fillable PDF) Telegu (fillable PDF) Tamil (fillable PDF) Vietnamese (fillable PDF)
23-032	In-State Child Abuse and Neglect Founded Findings Request	English (Word) English (PDF)
23-033	Child Abuse and Neglect Information Request	English (Word) English (PDF)
23-035	CHINS/ARY Report to Juvenile Court	English (Word) English (PDF)
23-036	Child Placing Agency Foster Home Licensing Investigation	English (Word)
23-036A	Child Placing Agency Foster Home Licensing Investigation Interviews	English (Word) English (PDF)
23-037	Background Clearance Notification	English (Word) English (PDF)
23-041	Washington State Child Abuse and Neglect Founded Findings Request from Another State	English (Word) English (PDF)
23-046	ECEAP Program Monitoring Community Partner Questionnaire	English (Word) English (PDF)
27-164	Single Parent Declaration	English (Word) English (PDF) Amharic (PDF) Arabic (PDF) Chinese (PDF) Farsi (PDF) Korean (PDF) Lingala (PDF) Marshallese (PDF) Oromo (PDF) Russian (PDF) Somali (PDF) Spanish (PDF) Swahili (PDF) Tigrinya (PDF) Trukese (PDF) Portugese (PDF) Vietnamese (PDF)

Provider Change Form

English (PDF)

Provider Direct Deposit Authorization Form

English (PDF)

State Fiscal Quarterly Report

English (Excel)

Provider Registration Form

English (PDF)

File Checklist (Kinship License)

English (Word)

00-002

COVID- 19 Prevention, Intervention and Quarantine Plan

English (Word)

00-005

HVSA Expansion Application Template

English (Word)

00-005A

2022 Spring HVSA Tribal Expansion Funding Application

English (Word)

02-003

Application for Early Learning Advisory Council

English (Word)

02-003a

Application for Provider Supports Subcommittee

English (Word)

02-003b

Parent Advisory Group (PAG) Application

English (Word)
Spanish (Word)
Spanish (PDF)

02-006

Treatment Foster Care Initiative (TFCI) Referral

English (Word)
Treatment Foster Care Initiative (TFCI) Information

02-020

Guide to Background Checks

English (PDF)

02-026

Unsung Hero Nomination Form

English (Word)
English (PDF)
Somali (Word)
Spanish (Word)

02-031

WA State Citizen Review Panels (CRP) Data Request Form

English (Word)

02-206

Statement of Earnings

English (Word)
English (PDF)
Albanian (PDF)
Spanish (PDF)

03-374B

Agreement on Nondisclosure of Confidential Information-Non Employee

English (Word)
English (PDF)

03-415

Facility Short Term Use Application

English (Word)
English (PDF)

03-492

Foster Parent Recipient Shared Leave

English (Word)
English (PDF)

03-493

Foster Parent Donor Shared Leave

English (Word)
English (PDF)

04-220

Family Ancestry Chart

English (Word)
English (PDF)

04-225

CBCAP Quarterly Report

English (Word)

05-001

Expression of Interest

English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

05-002

Funding Organization Commitment

English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (PDF0
Spanish (Word)

05-003

Provider Application Form

English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

05-004

ECEAP Community Funded

English (Word)
English (PDF)
Somali (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

05-005

Education Appeal

English (Word)
English (PDF)

05-006

2022-2023 ECEAP Prescreen and Application Combined Form

English 2022-2023 Combined (PDF)
English 2022-2023 Prescreen (PDF)
English 2022-2023 Application
Spanish 2022-2023 Combined (fillable PDF)
Spanish 2022-2023 Prescreen (fillable PDF)
Spanish 2022-2023 Application (fillable PDF)
Amharic 2022-2023 Combined Application and Prescreen
Arabic 2022-2023 Combined Application and Prescreen
Russian 2022-2023 Combined Application and Prescreen
Ukranian 2022-2023 Combined Application and Prescreen
Vietnamese 2022-2023 Combined Application and Prescreen

05-007

ECEAP Contractor Financial Disclosure Certification

English (PDF)

05-008

Early ECEAP Prescreen & Application (Combined Form)

English 2022-2023 Combined (PDF)
English 2022-2023 Prescreen (PDF)
English 2022-2023 Application (PDF)
Spanish 2022-2023 Application (fillable PDF)
Spanish 2022-2023 Prescreen (fillable PDF)
Spanish 2022-2023 Application (fillable PDF)

05-009

ECEAP Professional Development Plan Assistant Teacher

English (Word)
English (PDF)

05-010

ECEAP Professional Development Plan Lead Teacher

English (Word)
English (PDF)

05-011

ECEAP Professional Development Plan Family Support Staff

English (Word)
English (PDF)

05-012

Approval of New Early ECEAP Site/Classroom

English (Word)

05-021

ECEAP Contractor Alternative Attendance Plan Request

English (Word)
English (PDF)

05-022

ECEAP Contract Waiver-Variance Request to ECEAP Requirements

English (Word)
English (PDF)

05-023

ECEAP Contractor Purchase Request

English (Word)
English (PDF)

05-024

ECEAP Contractor Equipment Disposal Request

English (Word)
English (PDF)

05-026A

ECEAP and B-3 Services Application

Exhibit A: ECEAP and B-3 Services Application
Exhbit B: Letters of Support and Collaboration
Exhibit C: Coordination with Neighboring Head Start/ECEAP and Tribal Organizations (Scored)
Exhibit D: Budget
Exhibit F: Certifications and Assurances

05-027

ECLIPSE Services Application Packet

Exhibit D: Startup Budget
Exhibit E: ECLIPSE Services Application Form
Exhibit F: Certifications and Assurances

05-031

Parent Consent to Transfer ELMS Records

English (Word)
English (PDF)
Spanish (PDF)

05-032

ECEAP Complex Needs Fund (CNF) Grant Application Guidance

English Application Guidance (PDF)

05-034

ECLIPSE RFA Applications and Guides

Request for Application References
Budget Form
ECLIPSE Request for Application Guide
ECLIPSE Minimum Service Delivery Requirements Table

05-041

Licensing Dvisions Practice Change Request Review & Approval

English (Word)

05-041A

Licensing Division Practice Change Request

English (Word)

05-050

Citizen Review Panel Membership Application

English (Word)

05-051

Citizen Review Panel Confidentiality Agreement

English (Word)

05-250

Certification Regarding Environmental Tobacco Smoke

English (Word)
English (PDF)

05-305

ADA/504 Discrimination Complaint/Grievance Form

English (PDF)

05-320

2018-19 Financial Disclosure Certification

English (PDF)

05-325

ECEAP Porgram Monitoring Document Review Checklist

English (Word)
English (PDF)

06-006

Pinwheel Order Form

English (PDF)

06-097

Provider File Action Request

English (Word)
English (PDF)

06-160

Adoption Support Monthly Counseling Billing

English (Word)
English (PDF)

06-165

Extended Foster Care (EFC) Denial Letter

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

06-166

Individual Training Plan

English (Word)
Spanish (Word)
Spanish (PDF)

06-172

Domestic Violence Prevention Account

English (Word)
English (PDF)

06-179

Education and Training Voucher (ETV) Spending Plan

English (Excel)

07-085

Client Travel Approval Quick Reference Guide

English (PDF)

07-090 Contact Forms Manager for translation revisions

Caregiver Monthly Transportation Reimbursement

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

07-110

Child Care Stabilization Grant Application – Family, Friend, and Neighbor (FFN) License- Exempt Providers

English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)

07-110A

Child Care Stabilization Grant Spend Period Extension Request

English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)

07-110B

Stabilization Grant Receipt Verification Form Program and Add-On Amounts

English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

07-110C

Stabilization Grant Receipt Verification Form Workforce Amounts

English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

07-112

Spring 2021 Child Care COVID -19 Grant Receipt Verification

English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)

07-112a

Early Achievers Needs-Based Grant Receipt Verification Form

English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

08-050

Request/Certification of Data Destruction

English (Word)
English (PDF)

09-007

Petition for Review of Initial Decision (Appeal)

English (Word)
English (PDF)

09-010

Child Welfare History

English (Word)

09-012

Request for Certificate of Parental Improvement (CPI)

English (Word)
English (PDF)

09-013

Vendor Affidavit of Lost, Stolen or Destroyed Warrant

English (Word)
English (PDF)

09-026

DSO & Jail Removal Data Form

English (Word)

09-031

Authorization By Subject of Records Requested

English (Word)
English (PDF)

09-054

Waiver of Notice of Further Hearing

English (Word)
English (PDF)

09-056

Dependent/Ward of the Court Verification

English (Word)
English (PDF)

09-082

Five Day Notification to Move

English (Word)
English (PDF)

09-093

School Notification

English (Word)
English (PDF)

09-095

Court Report

English (Word)
English (PDF)

09-100

Hiring Education Affidavit Request (Early Learning)

English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

09-101

Hiring Education Affidavit Request (School Age)

English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

09-102

Hiring Education Affidavit Request (Outdoor Nature-Based)

English (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

09-104

ICPC Closure Letter

English (Word)
English (PDF)

09-111

Continuous Quality Improvement Confidentiality Agreement

English (Word)
English (PDF)

09-126

Local Indian Child Welfare Advisory Committee Confidentiality Agreement

English (Word)
English (PDF)

09-127

Rights of Children and Youth in Foster Care

English (Word)
English (PDF)

09-128

Child Fatality Case Review Confidentiality Agreement

English (Word)
English (PDF)

09-129

Child Near Fatality Case Review Confidentiality Agreement

English (Word)
English (PDF)

09-131

Background Check Request/Decision

English (Word)
English (PDF)
Marshallese (PDF)
Spanish (Word)
Spanish (PDF)

09-132

Employee Background Check Request/Summary

English (Word)
English (PDF)

09-154

NCIC Purpose Code C Background Check Summary

English (Word)
English (PDF)

09-160

Background Check Hearing Request Form

English (Word)
English (PDF)

09-162

Background Check Reconsideration Request

English (Word)
English (PDF)

09-164

Request for Early Learning Background Check Results

English (Word)
English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)

09-165

Portable Background Check Application

English (PDF)

09-539

Inquiry to Indian Tribe

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

09-611

Release and Consent for Child Specific Recruitment

English (Word)
English (PDF)

09-653

Background Check Authorization

English (Word)
English (PDF)
Cambodian (PDF)
Chinese (PDF)
Chinese (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Vietnamese (PDF)

09-761

Indian Identity Request

English (Word)
English (PDF)

09-765

Declaration of Adoption Facilitator - Indian Child

English (Word)
English (PDF)

09-837

Disclosure of Confidential HIV / AIDS Information

English (Word)
English (PDF)

09-966

Authorization to Release Information to the Court

English (Word)
English (PDF)

09-979

Marital/Domestic Partnership History

English (Word)

09-997

Adoption Support Worksheet

English (Word)
English (PDF)
Vietnamese (PDF)

09-998

Application for the Adoption Support Program and/or Reimbursement of Adoption Finalization Costs

English (Word)
English (PDF)
Vietnamese (PDF)

10-016

File Checklist and Certification for License of Foster Home

English (Word)

10-017

Termination of Foster Home License

English (Word)
English (PDF)

10-042

Child Protective Services Casework Checklist

English (Word)
English (PDF)

10-043

Home Study

English (Word)

10-061

Child’s Registration

English (Word)
English (PDF)

10-082

Adoption Support Agreement Review

English (Word)
English (PDF)
Spanish (PDF)
Spanish (Word)

10-083

Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Assessment

English (Word)
English (PDF)

10-114

Adoption Data Card

English (Word)
English (PDF)

10-166A

Behavioral Rehabilitation (BRS) Referral

English (Word)
English (PDF)

10-182

File Checklist (Forster License)

English (Word)

10-182A

File Checklist (Unlicensed)

English (Word)
Spanish (Word)
Spanish (PDF)

10-182B

File Checklist (Provisional Expedited License)

English (Word)

10-183

Home Inspection Checklist (Licensed)

English (Word)
Spanish (Word)
Spanish (PDF)

10-214

Pre-Authorization For Services

English (Word)
English (PDF)

10-248

Compliance Agreement

English (Word)
Spanish (PDF)
Spanish (Word)

10-248A

Compliance Agreement Continuation

English (Word)
English (PDF)

10-261

Foster Care Rate Assessment

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

10-290

WAC Agreements

English (Word)
Marshallese (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)

10-354

Home Study or Reassessment Application

English (Word)
Oromo (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

10-395

Intensive Family Service Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary

English (Word)
English (PDF)

10-405

Foster Home Reassessment

English (Word)

10-406

Employed Foster Parent Child Care Plan

English (Word)
English (PDF)

10-408

Application for Child Care Agency License or Certification

English (Word)
English (PDF)

10-416

Foster Home Monitoring Visit

English (Word)

10-419

Supervision Plan for Site Specific Conditions

English (Word)
Spanish (PDF)

10-425

Reference Questionnaire (Certified Respite)

English (Word)
Spanish (Word)
Spanish (PDF)

10-428

Caregiver Support Plan

English (Word)
English (PDF)

10-429

New License Letter

English (Word)
Spanish (Word)
Russian (Word)
Russian (PDF)
Somali (Word)
Somali (PDF)
Spanish (PDF)

10-432

Extended Foster Care Program Participation Agreement

English (Word)
English (PDF)
Mam (PDF)
Spanish (Word)
Spanish (PDF)

10-453

Home Inspection Checklist (Unlicensed)

English (Word)

10-454

DCYF Caregiver Authorization

English (PDF)
Laotian (PDF)

10-455

Medication Log

English (Word)
English (PDF)

10-458

Home Study Referral Notice

English (Word)
English (PDF)

10-459

Courtesy Supervision Referral

English (Word)
English (PDF)

10-460

Treehouse Educational Advocacy Referral

English (Word)
English (PDF)

10-462

User Application and Acknowledgement

English (Word)
English (PDF)

10-463

FamLink Data Access Request / Change

English (Word)
English (PDF)

10-464

FamLink Access Application and Acknowledgement

English (Word)
English (PDF)

10-474

FAR Family Assessment

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Cambodian (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Vietnamese (PDF)

10-475

Early Invention Program (EIP) Exit Summary

English (Word)
English (PDF)

10-477

Adoption Support Program Application Checklist

English (Word)
English (PDF)

10-479

Early Intervention Program (EIP) 90 Day Review

English (Word)
English (PDF)

10-479

Early Intervention Program (EIP) 90 Day Review

English (Word)
English (PDF)

10-480

Comprehensive Family Evaluation

English (Word)
English (PDF)

10-484

Youth Run Prevention Plan

English (Word)
English (PDF)

10-490

Child Specific Contract or Extra Supervision Rate Proposal

English Excel

10-500

Acknowledgement of Child(ren)’s Adoptive File Provided to Adoptive Family:

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

10-507

Orientation Sign-In Sheet

English (Word)
English (PDF)

10-537

Interstate Compact for the Placement of Children (ICPC) Parent Home Study Information

10-537
10-537
Spanish (PDF)
Spanish (Word)

10-539

Interstate Compact for the Placement of Children (ICPC) Reference Questionnaire for Parent Home Study

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

10-540

Project SafeCare Monthly Summary

English (Word)
English (PDF)

10-545

Family Feedback Questionnaire

English (Word)
English (PDF)

10-546

Adoption Archive Request for Non-Identifying Information

English (Word)
English (PDF)

10-547

Adoption Support Limitations Letter

English (Word)
English (PDF)
Somali (PDF)
Vietnamese (PDF)

10-566

Contracted Health and Safety Visit Referral

English (Word)
English (PDF)

10-567

Contracted Health and Safety Visit Report

English (Word)
English (PDF)

10-578

Licensing Application Checklist

English (Word)
English (PDF)
Amharic (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)

10-581

Unlicensed Placement Application Checklist

English (Word)
English (PDF)
Spanish (PDF)
Spanish (Word)

10-606

Adoptive Parent Counseling Preauthorization for Services

English (Word)
English (PDF)

10-650

ESIT Authorization for Release of Records

English (PDF)
Amharic (PDF)
Arabic (PDF)
Chinese (PDF)
Farsi (PDF)
Khmer (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Urdu (PDF)
Vietnamese (PDF)

11-010

Funding Opportunity: Perinatal Mental Health Community Capacity Building

English (Word)
English (PDF)

11-011

2022 Spring HVSA Expansion Funding Opportunity Letter of Intent to Apply

English (Word)

11-011A

HVSA Tribal Home Visiting Funding Opportunity Letter of Intent

English (Word)

11-013

Community Based Child Abuse Prevention (CBCAP) Funding Opportunity

English (Word)

11-014

Family Resource Center Capacity Building Funding Opportunity

English (Word)

11-015

CBCAP Returning Programs

English (Word)

11-016

Perinatal Mental Health Year-End Community Report Template

English (Word)

11-017

Diaper Bank Partnership Quarterly Report Form

English (Word)

11-018

Perinatal Mental Health Returning Program

English (Word)

11-019

Diaper Bank Concrete Good for Families Quarterly Report Form

English (Word)

11-020

Tribal Fatherhood Support Program Funding Opportunity

English (Word)

11-021

HV-BAT Supplemental Form

English (Word)

11-022

Family Resource Center Capacity Building Work Plan

English (Word)

11-023

FRC Quarterly Report Form

English (Word)

11-024

Tribal Fatherhood Supports Plan

English (Word)

11-025

Option 1A

English (Excel)

11-026

Option 1B

English (Excel)

11-027

Option 2

English (Excel)

11-028

Tribal Fatherhood Quarterly Reports

English (Word)

12-001

Special Needs Child Care Rate Request

English (Word)
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Dari (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Pashtu (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tigrigna (PDF)
Urdu (PDF)
Vietnamese (PDF)

13-001

Applicant Medical Report- Confidential

English (Word)
Oromo (PDF)
Spanish (Word)
Spanish (PDF)
Somali (PDF)
Tagalog (PDF)
Vietnamese (PDF)

13-001A

Applicant Medical Self Report

English (Word)
Marshallese (PDF)
Oromo (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)

13-001B

Applicant Mental Health Report

English (Word)
Spanish (PDF)

13-041

Child's Medical and Family Background Report

English (Word)
English (PDF)
Cambodian (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Russian (PDF)

13-904

Diabetes Care and Action Plan

English (Word)
English (PDF)

13-907

Brief Assessment of Anxiety and PTSD: Caregiver/Parent

English (Word)
English (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)

14-001

Employment Verification for State Training

English (Word)
English (PDF)

14-002

Trainer Observation Rubric

English (Word)
English (PDF)

14-003

Trainer Observation Rubric (Self Paced)

English (Word)

14-005

OJJDP Title II Pass Through Fund

English (Word)

14-011

Enrollment Application Medical and Dental Benefits

English (PDF) If using chrome, save form to desktop before filling in form
Somali (PDF)
Spanish (PDF)

14-011a

Change Form Medical and Dental Benefits

English (PDF)
Spanish (fillable PDF)
Somali (fillable PDF)

14-012

Consent

English (Word)
Marshallese (PDF)
Spanish (Word)
Spanish (PDF)
Swahili (PDF)

14-252

Employment Verification

English (Word)
English (PDF)
Albanian (PDF)
Amharic (PDF)
Cambodian (PDF)
Chinese (PDF)
Dar (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Lingala (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Swahili (PDF)
Tagalog (PDF)
Turkish (PDF)
Ukaranian (PDF)
Vietnamese (PDF)

14-255

Early Childhood Equity Grant Application

English (Word)
Arabic (PDF)
Chinese (PDF)
Russian (PDF)
Somali (Word)
Spanish (Word)

14-281

Source of Funds Application for Child in Placement

English (Word)
English (PDF)

14-293

Title IV-E Initial Eligibility Determination Income Calculation Worksheet

English (Word)
English (PDF)

14-319

IV-E Eligibility Determination for an Adoption Support Application

English (Word)
English (PDF)

14-319A

IV-E Eligibility Determination For R-GAP, Relative Guardianship Assistance Program

English (Word)
English (PDF)

14-417

CCSP Application

Chinese (PDF)
Korean (PDF)
Pashtu (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
Vietnamese (PDF)

14-417A

Family, Friend, and Neighbor (FFN) In-Home/Relative Pending Letter

English (Word)
Amharic (PDF)
Dari (PDF)
Oromo (PDF)
Russian (PDF)
Spanish (Word)
Spanish (PDF)
Ukranian (PDF)

14-434

Title IV-E Requirements for Out of State Foster Care Payments

English (Word)
English (PDF)

14-435

Provider Employment Eligibility Verification

English (Word)
English (PDF)

14-438

Stop Work

English (Word)
Arabic (PDF)
Dari (PDF)
Oromo (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Tigrigna (PDF)
Vietnamese (PDF)

14-444

Child Health and Education Tracking Screening Report

English (Word)
Mam (PDF)
Marshallese (PDF)
Spanish (Word)
Spanish (PDF)

14-446

Declaration of Financial Status for Adoption Support Application

English (Word)
English (PDF)

14-452

Financial Worksheet

English (Word)
English (PDF)
Marshallese (PDF)
Oromo (PDF)
Spanish (Word)
Spanish (PDF)
Somali (PDF)
Tagalog (PDF)
Vietnamese (PDF)

14-474

Shared Planning Meeting

English (Word)
Spanish (Word)
Spanish (PDF)
Cambodian (PDF)
Chinese (PDF)
Korean (PDF)
Mandinka (PDF)
Russian (PDF)
Somali (PDF)
Swahili (PDF)
Thai (PDF)
Tigrinya (PDF)
Trukese (PDF)
Vietnamese (PDF)

14-510

Certified Respite Provider Agreements

English (Word)
English (PDF)
Spanish (PDF)
Spanish (Word)

14-512

Application for Certified Respite Provider

English (Word)
English (PDF)
Spanish (Word)
Spanish (fillable PDF)

14-531

Education and Training Voucher (ETV) Program and Passport to Careers Program 2023 – 2024 Application

English (Word)
English (PDF)

14-531A

Education and Training Voucher (ETV) Program and Passport to Careers Program Application Consent

English (Word)
English (PDF)

14-545

Extended Adoption Support Application

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

14-548

Independent (IL) / Transitional Living (TL) Grant Application

English (Word)
English (PDF)

14-600

Interim Individualized Family Service Plans (IFSP) (ESIT)

English (Word)

15-005

ESIT Health Care Referral Form

English (Word)
English (PDF)

15-015

Child Care Subsidy Program Site Change Form

English (Word)
English (PDF)

15-016

HVSA Local Implementing Agency Contact Update Form

English (Word)
English (PDF)

15-025

ESIT COVID-19 IFSP Review Form

English (Word)
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (fillable PDF)
Chinese (fillable PDF)
Farsi (PDF)
Korean (fillable PDF)
Laotian (fillable PDF)
Punjabi (fillable PDF)
Russian (fillable PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
Telugu (fillable PDF)
Tamil (fillable PDF)
Urdu (PDF)
Vietnamese (fillable PDF)

15-027

Professional Services Referral

English (Word)
English (PDF)
Kanjobal (PDF)

15-028

Psychological Services Referral

English (Word)
English (PDF)

15-029

Psychiatric Services Referral

English (Word)
English (PDF)

15-030

SUS Residential Referral Form

English (Word)
English (PDF)

15-050

Confirmation of Individualized Family Service Plan (IFSP) Schedule

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-051

Declining One or More Early Intervention Services

English
Amharic (PDF)
Arabic
Cambodian
Chinese
Farsi
Korean
Laotian
Punjabi (PDF)
Russian
Somali
Spanish
Tamil
Telugu (PDF)
Ukrainian (PDF)
Urdu
Vietnamese

15-052

Declining Participation in the ESIT Program

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-053

Formal Dispute Resolution Request

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Laotian (PDF)
Marshallese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-054

Notice and Consent for Evaluation/Assessment

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukranian (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-055

Individualized Family Service Plan (IFSP)

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Telugu (PDF)
Tamil (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-056

Notice of Consent for Initial Evaluation Assessment

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
French (PDF)
Korean (PDF)
Laotian (PDF)
Mashallese (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telegu (PDF)
Ukranian (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-057

Notice and Consent for Screening

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-058

Parent Prior Written Notice

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese (PDF)

15-059

Prior Written Notice Consent and Financial Information Forms

English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Laotian (PDF)
Punjabi (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tamil (PDF)
Telugu (PDF)
Ukrainian (PDF)
Urdu (PDF)
Vietnamese

15-060

Adoption Purchase of Services Contracted Out of State Health and Safety Visit Report

English (Word)

15-092

The Interstate Compact on the Placement of Children (ICPC) Placement Request

English (Word)
English (PDF)

15-093

Interstate Compact on the Placement of Children (ICPC) Report on Child’s Placement Date or Change of Placement – 100B

English (Word)
English (PDF)

15-128

Verification of Indian Status: Foster Care and Adoptive Applicant

English (Word)
English (PDF)
Marshallese (PDF)

15-209A

Health/Mental Health and Education Summary

English (Word)
English (PDF)

15-209C

Visit Plan

English (Word)
English (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Tagalog (PDF)
Tigrigna (PDF)
Ukrainian (PDF)
Vietnamese (PDF)

15-245

LIMITED ENGLISH PROFICIENT (LEP)/DEAF CLIENT SERVICES LEP Client Service Record

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

15-258

Safety Assessment/Safety Plan

English (Word)
Russian (PDF)

15-259

Safety Plan

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Amharic (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Punjabi (PDF)
Russian (PDF)
Somali PDF)
Tagalog (PDF)
Tigrigna (PDF)
Ukrainian (PDF)
Vietnamese (PDF)

15-259A

Case Plan

English (Word)
English (PDF)
Chinese (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)

15-260

Parents Information Sheet for Shared Planning Meetings and Staffings

English (Word)
English (PDF)

15-266

Child Protect Teams (CPT) Staffing Recommendations

English (Word)
English (PDF)

15-267

Attendance and Confidentiality Agreement

English (Word)
English (PDF)
Vietnamese (PDF)

15-268

Child Protect Teams (CPT) Case Presentation Summary

English (Word)
English (PDF)

15-276

Personal Information

English (WORD)
Somali (PDF)
Spanish (PDF)
Spanish (Word)
Tagalog (PDF)

15-280

Unlicensed Caregiver Placement Checklist

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

15-281

Placement Agreement

English (PDF) Contact forms manager for translation revisions as of 3/8/2021
Spanish(PDF) if using Chrome download to desktop to fill out form

15-286

Reference Questionnaire

English (Word)
English (PDF)
Arabic (PDF)
Marhsallese (PDF)
Spanish (Word)
Spanish (PDF)
Tagalog (PDF)

15-286A

Adult Child Reference Questionnaire

English (Word)
English (PDF)
Arabic (PDF)
Marshallese (PDF)
Spanish (PDF)
Tagalog (PDF)

15-300

Child Information and Placement Referral

English (Word)
English (PDF)

15-308

Missing Child Staffing

English (Word)
English (PDF)

15-309

Returning Child De-Briefing

English (Word)
English (PDF)

15-313

Caregiver’s Report to the Court

English (Word)
English (PDF)
Spanish (PDF)

15-322

Long Term Care Agreement for Foster Parents or Relative Caregivers

English (Word)
English (PDF)

15-324

Guardianship Approval Checklist

English (Word)

15-359

Child's Physical Description

English (Word)
English (PDF)

15-362

Concurrent TANF Benefits/Family Reunification Notice of Removal from TANF Home

English (Word)
English (PDF)

15-363B

Provider Notification of Visit/Transport Schedule Initial Intake Screening Report

English (Word)
English (PDF)

15-363C

Visit Coordination Plan

English (Word)
English (PDF)

15-368

Education and Training Voucher (ETV) Program Participation Agreement

English (Word)
English (PDF)

15-368A

Education and Training Voucher (ETV) Program Dual Credit Participation Agreement

English (PDF)
English (Word)

15-369

Education and Training Voucher (ETV) Program 2023 - 2024 Renewal Application

English (Word)
English (PDF)

15-370

Education and Training Voucher (ETV) Program Payment Request

English (Word)
English (PDF)

15-372

Enumeration Referral

English (Word)
English (PDF)

15-377

Education and Training Voucher (ETV) Program Dual Credit Application

English (Word)

15-402

Notice to Foreign Consulate of Child Protection Proceedings

English (Word)
English (PDF)

15-411

Licensing Waiver/Administrative Approval/Relative Non-Safety Exemption

English (Word)
English (PDF)

15-411A

Licensing Waiver (Foster Home)

English (Word)

15-411D

Administrative Approval (Foster Home)

English (Word)

15-412

Request for Extension and Disability Verification for Youth Over Age 18

English (Word)
English (PDF)

15-416

Interstate Compact for Adoption Medical Assstance ICAMA

English (Word)

15-417

Transition Plan for Youth Exiting Care

English (Word)
English (PDF)

15-425

Adoption Redaction Request

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

15-428

Protective Action Plan

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)
Cambodian (PDF)
Chinese (PDF)
Korean (PDF)
Russian (PDF)
Somali (PDF)
Vietnamese (PDF)

15-431

Extended Foster Care Program Voluntary Placement Agreement (VPA)

English (Word)
English (PDF)
Dari (PDF)
Spanish (PDF)
Spanish (Word)

15-433

Incomplete Application

English (Word)
Russian (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

15-433A

Provisional Expedited Incomplete Application

English (Word)

15-434

On-Going Mental Health (OMH) Screening Report

English (Word)

15-448

Family Time Report

English (Word)

15-448A

Supported Visit Report

English (Word)
English (PDF)

15-450

Child Specific Caregiver Notification

English (Word)
English (PDF)

15-451

Missed and No Show Report: Parent – Child Visit

English (Word)
English (PDF)

15-452

Sibling Visit Report

English (Word)
English (PDF)

15-454

Unusual Incident Report

English (Word)

15-455

Vaccine Exemption

English (Word)
English (PDF)
Spanish (Word)
Spanish (fillable PDF)

15-460

Background Confirmation and Out of State Check

English (Word)
Farsi (PDF)
Spanish (PDF)
Spanish (Word)
Russian (PDF)

15-466

Contract Risk Assessment / Analysis

English (PDF)

15-469

Pre-Contract Action Request (P-CAR)

English (Word)
English (PDF)

15-470

DCYF Regional Contract Request

English (Word)
English (PDF)

15-472

After-the-Fact Contract Justification

English (Word)

15-491

Plan of Safe Care

English (Word)
English (PDF)
Arabic (PDF)
Cambodian (PDF)
Chinese (PDF)
Korean (PDF)
Laotian (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Vietnamese (PDF)

15-705

FFN Waiver Request

English (Word)
Spanish (Word)
Spanish (PDF)

15-707

School-Age Child Care Monitoring Checklist

English (Word)
English (PDF)

15-708

Child Care Center Monitoring Checklist (Example)

English (Word)

15-709

Family Home Child Care Monitoring Checklist (Example)

English (Word)

15-720

Interest Survey for Organization License Pilot

English (Word)
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)

15-820

Tuberculosis (TB) Screening LD

English (Word)
English (PDF)
Marshallese (PDF)
Spanish (PDF)
Vietnamese (PDF)

15-821

Infant Safety Agreement

English (Word)
Somali (PDF)
Spanish (Word)
Spanish (PDF)
Vietnamese (PDF)

15-821a

Infant Safety Certified Respite

English (Word)

15-822

Influenza Vaccination Agreement

English (Word)
Somali (PDF)
Spanish (Word)
Vietnamese (PDF)

15-822a

Vaccine Agreements Certified Respite

English (Word)
English (Word)
Spanish (Word)
Spanish (fillable PDF)

15-823

Pertussis Vaccination Agreement

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

15-824

Authorization and Consent to Share Records

English (Word)
Spanish (Word)
Spanish (PDF)

15-824A

Authorization and Consent to Share Records (CPA Home)

English (Word)

15-852

Plan to Meet Experience Qualification

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-853

Intent to Transfer License or Certification

English (Word)
English (PDF)
Somali (Word)
Somali (fillable PDF)
Spanish (Word)
Spanish (fillable PDF)

15-857

Parent/Provider Health Safety Agreement (FFN)

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-858

Emergency Contact and Permission Form (FFN)

English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)

15-859

Safety Record and Evacuation Plan

English (Word)
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)

15-860

Medication Permission Form For Illness and Allergies (FFN)

English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)

15-861

Initial Checklist for Child Care Center Applicant

English (Word)

15-862

Initial Checklist for Family Home Child Care Applicant

English (Word)

15-863

Initial Checklist for School-Age Program Applicant

English (Word)

15-874

Capacity Increase Change Planning Guide

English (Word)
English (PDF)

15-879

Child Care Registration

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-891

Chimney, Fireplace, Woodstove Use Statement

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-892

Fire, Safety, Emergency Drills Record

English (Word)
Somali (PDF)
Spanish (PDF)

15-894

Family Home Child Care Liability Insurance Form

Engllish (Word)
English (PDF)
Somali (PDF)
Spanish PDF)

15-895

Overnight Child Care Planning Guide

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-896

Probation Notification Letter to Parents from Provider

English (Word)

15-897

Child Care Parent Guardian Permissions

English (Word)
English (PDF)
Somali (Word)
Spanish (Word)

15-899

Child Licensee or Assistant Resume

English (Word)
English PDF)
Somali (PDF)

15-937

Child Care Center School-Age Background Checklist

English (Word)
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)

15-939

Hearing Request

English (Word)
English (PDF)
Somali (PDF)

15-941

Child Care Injury Incident Report

Engllish (Word)
English (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

15-942

Daily Child Attendance Records

English (Word)
English (PDF)
Somali (PDF)

15-943

Child Care Agreement

English (Word)
Spanish (Word)

15-945

Tribal Certification Request

English (Word)

15-949

Family Home Child Care Background Checklist

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-952

Notification to Parents and Guardian - Safe Sleep Non-Compliance

English (W0rd)
English (PDF)
Somalie (PDF)
Spanish (PDF)

15-954

Notification of Staffing Plan Absence

English (Word)
Somali (PDF)
Spanish (PDF)

15-955

Family Home and Center Child Care License or Certification Application

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)

15-956

No Social Security Card Declaration

English (Word)
Somali (PDF)
Spanish (PDF)

15-957

Child Care Variance Request

English (Word)
Somali (PDF)
Spanish (PDF)

15-961

Child Care Waiver Request

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-963

Early Learning-Child Care Facility Feasibility Checklist

English (Word)

15-964

Early Learning-Child Care Facility Feasibility Checklist (sa)

English (Word)

15-965

Sanitizer Disinfectant Approval Request

English (Word)
Somali (PDF)
Spanish (PDF)
Spanish (Word)

15-966

Child Care Health Consultant Agreement

Engllish (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-967

Child Care Health Consultant Onsite Report

English (Word)
Engllish (PDF)
Somali (PDF)
Spanish (PDF)

15-968

Child Care Medication Authorization

English (Word)
English (PDF)
Somali (PDF)
Spanish (PDF)

15-969

Child Care Medication Log

Englislh (Word)
Somali (PDF)
Spanish (PDF)

15-970

Individual Care Plan for Child in Child Care

English (Word)
English (PDF)
Spanish (PDF)

15-974

Declaration of Compliance

English (Word)
English (PDF)
Somali (fillable PDF)
Spanish (fillable PDF)

15-980

School Age License Application

English (PDF)

16-005

Electronice Attendance Provider Welcome Letter (Barcode)

English (Word)
English (PDF)

16-010

Parental Advisory Group (PAG) Cover Letter and Application

English (Word)
Somali (fillable PDF)
Spanish (fillable PDF)
Spanish (Word)

16-015

State Approved Training Concern Form

English (Word)
English (PDF)

16-025

Contractor Certification

English (Word)

16-030

Book Review Worksheet for Foster Parent Training Hours

English (Word)
Spanish (Word)
Spanish (PDF)

16-179

Reference Questionnaire Request

English (Word)
English (PDF)
Arabic (PDF)
Spanish (Word)
Spanish (PDF)

16-204

Emergency and Evacuation Plan

English (Word)

16-209

Archived Records Memo Adoption and/or Legally Free Children Aged Out

English (Word)
English (PDF)

16-211

Licensing Division (LD) Agency Letter of Reference

English (Word)
English (PDF)

16-217

Washington State ICPC Quarterly Supervision Report

English (Word)
English (PDF)

16-225

File Checklist (Certified Respite)

English (Word)
Spanish (Word)
Spanish (PDF)

16-235

Media Release

English (PDF)

17-041A

Request for DCYF Records

English (Word)
Russian (PDF)
Somali (PDF)
Spanish (Word)
Spanish (PDF)

17-063

Written Authorization

English (Word)
English (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Spanish (Word)

17-215

DCYF Checklist: Subcontractor Approval Request

English (Word)
English (PDF)

17-215A

DCYF Checklist: Subcontractor Approval Request

English (Word)
English (PDF)

17-251

FERPA Access Request

English (Word)
English (PDF)

18-400

Foster Reimbursement Claim

English (Word)
English (PDF)
Spanish (Word)
Spanish (PDF)

18-400A

Third Party Claim Checklist

English (Word)
English (PDF)

20-015

Juvenile Rehabilitation Youth Engagement Request

English (Word)

20-016

JR Marriage Approval for Release of Information

English (Word)
English (PDF)

20-017

JR Marriage Application

English (Word)
English (PDF)

20-020

Acknowledgement of JR Policy 6.70 Marriage in JR Facilities

English (Word)
English (PDF)

23-005

Three-Pronged Approach (TPA) I. Parent Inerview Questions Related to Vision and Hearing

English (PDF)
Amharic (fillable PDF)
Arabic (fillable PDF)
Bengali (fillable PDF)
Cambodian (fillable PDF)
Chinese Simplified (fillable PDF)
Chinese Traditional (fillable PDF)
Dari (fillable PDF)
Farsi (fillable PDF)
French (fillable PDF)
Hindi (fillable PDF)
Japanese (fillable PDF)
Kannada (PDF)
Korean (fillable PDF)
Marshallese (PDF)
Nepali (fillable PDF)
Pashtu (fillable PDF)
Portuguese (fillable PDF)
Punjabi (fillable PDF)
Russian (fillable PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
Tagalog (fillable PDF)
Telugu (fillable PDF)
Tigrigna (fillable PDF)
Tamil (fillable PDF)
Vietnamese (fillable PDF)

23-006

Three Pronged Approach (TPA) II. Developmental Skills Checklist Related to Vision and Hearing in Young Children

English (Word)
English (PDF)
Amharic (fillable PDF)
Arabic (fillable PDF)
Bengali (fillable PDF)
Cambodian (fillable PDF)
Chinese Simplified (fillable PDF)
Chinese Traditional (fillable PDF)
Dari (fillable PDF)
Farsi (fillable PDF)
French (fillable PDF)
Hindi (fillable PDF)
Japanese (fillable PDF)
Kannada (PDF)
Korean (fillable PDF)
Marhsallese (fillable PDF)
Nepali (fillable PDF)
Pashtu (fillable PDF)
Portuguese (fillable PDF)
Punjabi (fillable PDF)
Russian (fillable PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
Tagalog (fillable PDF)
Telugu (fillable PDF)
Tigrigna (fillable PDF)
Tamil (fillable PDF)
Vietnamese (fillable PDF)

23-007

Three-Pronged Approach (TPA) Summary Form Addressing Vision and Hearing Concerns

English (Word)
English (PDF)
Amharic (fillable PDF)
Arabic (fillable PDF)
Bengali (fillable PDF)
Cambodian (fillable PDF)
Chinese Simplified (fillable PDF)
Chinese Traditional (fillable PDF)
Dari (fillable PDF)
Farsi (fillable PDF)
French (fillable PDF)
Hindi (fillable PDF)
Japanese (fillable PDF)
Kannada (PDF)
Korean (fillable PDF)
Marhsallese (fillable PDF)
Nepali (fillable PDF)
Pashtu (fillable PDF)
Portuguese (fillable PDF)
Punjabi (fillable PDF)
Russian (fillable PDF)
Somali (fillable PDF)
Spanish (fillable PDF)
Tagalog (fillable PDF)
Tigringa (fillable PDF)
Telegu (fillable PDF)
Tamil (fillable PDF)
Vietnamese (fillable PDF)

23-032

In-State Child Abuse and Neglect Founded Findings Request

English (Word)
English (PDF)

23-033

Child Abuse and Neglect Information Request

English (Word)
English (PDF)

23-035

CHINS/ARY Report to Juvenile Court

English (Word)
English (PDF)

23-036

Child Placing Agency Foster Home Licensing Investigation

English (Word)

23-036A

Child Placing Agency Foster Home Licensing Investigation Interviews

English (Word)
English (PDF)

23-037

Background Clearance Notification

English (Word)
English (PDF)

23-041

Washington State Child Abuse and Neglect Founded Findings Request from Another State

English (Word)
English (PDF)

23-046

ECEAP Program Monitoring Community Partner Questionnaire

English (Word)
English (PDF)

27-164

Single Parent Declaration

English (Word)
English (PDF)
Amharic (PDF)
Arabic (PDF)
Chinese (PDF)
Farsi (PDF)
Korean (PDF)
Lingala (PDF)
Marshallese (PDF)
Oromo (PDF)
Russian (PDF)
Somali (PDF)
Spanish (PDF)
Swahili (PDF)
Tigrinya (PDF)
Trukese (PDF)
Portugese (PDF)
Vietnamese (PDF)

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