Foster Home Environmental Conditions and Health Regulations Checklist 

 

Name: 
(Name) 


Address: 
(Address) 
_ 
City, State, Zip: 
(City, State, Zip) 
__ 
Telephone: 
(text) 
_ 


Yes No 

1) Home and yard are maintained, repaired, and are not hazardous to 




 children in care. 
(text) 
_____ 
(text) 


 

2) The house is free of uncontrolled rodents and insects. 
(text) 
_____ 
(text) 



3) Windows and doors used for ventilation are screened. 
(text) 
_____ 
(text) 





 

4) The kitchen is equipped with an operable stove, refrigerator, and 




 running water. 
(text) 
_____ 
(text) 


 

5) There are sufficient eating, cooking and drinking utensils to 




 accommodate all household members. 
(text) 
_____ 
(text) 


6) Household equipment and furniture are in good repair. 
(text) 
_____ 
(text) 





 

7) Flammable and poisonous substances, medications, and cleaning 




 materials are stored out of reach of children placed for foster care. 
(text) 
_____ 
(text) 


8) Explosive materials, ammunition and firearms are stored in separate 
locked places. 
(text) 
_____ 
(text) 





 

9) Documentation that household pets have been vaccinated for rabies 
is maintained by the foster parents. 
(text) 
_____ 
(text) 



10) Home has heating, air cooling or ventilating capability to maintain 




 comfort range between 65° and 85° Fahrenheit. 
(text) 
_____
(text) 


11) Rooms including toilets, baths, and kitchens without operable windows 




 have mechanical ventilation to outside. 
(text) 
_____ 
(text) 


 

12) Discussion of water quality, and sanitary toilet and bathing facilities held. 
(text) 
_____
(text) 





 

13) Discussion of Building Code held. 
(text) 
_____
(text) 





 

Remarks and recommendations: 
(text) 
(Remarks and recommendations [1]) 


_ 
_ 


Foster Parent Signature: 
(signature) 
_ 


Social Worker Signature: 
(signature) 
_ 


Social Worker Title: 
(Worker Title) 
Date: 
(Date) 
_ 






DSS-5150 (Rev. 09-01-07) 

North Carolina Division of Social Services 

Family Support and Child Welfare Services