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This checklist and all supporting documentation should be kept in a separate binder with the case file
Determination That Child Is An Indian
| 1. | ____ Reason to believe that this child is an Indian: |
Documentation of Information and its source and date:
| 2. | ____Child is a member of an Indian tribe or |
____Child is eligible for membership in an Indian tribe and is the biological child of a member of an Indian tribe
| 3. | ____Verification received of the child’s status from the Bureau of Indian Affairs, Department of the Interior or from the tribe (specify) |
Notice
| 4. | Does ICWA apply? _____________ Judicial Determination? _______________ |
If judicial determination, date: _______________
| 5. | Notice Date of CPS Proceeding Method |
mother __________________ _________
father ___________________ _________
GAL _____________________ _________
custodian ________________ _________
tribe _____________________ _________
BIA (if tribe unknown) ____ _________
Other ___________________ _________
Notice must be received ten days before any involuntary proceeding is held.
Placement - Least Restrictive Setting
| 6. | ICWA Preferences (A check mark means that this preference has been addressed and ruled out or placement has been made. For each preference listed, please indicate the location of records showing contacts with the Band and efforts to comply.) *Please note that, by statute, equal preference is given to b) and c) below. |
| (a) | ____ Member of extended family ; |
| (b) | ____ Native American licensed foster home ; |
| (c) | ____ Unlicensed Native American foster home approved by the tribe or band ; |
| (d) | ____ Institution for children approved by the tribe or operated by an Indian organization. |
| 7. | Good Cause to modify ICWA Placement Preferences listed in #6 above (Please indicate the location of records supporting good cause.): |
| (a) | ____Request by the parents or the child (if of sufficient age) ; |
| (b) | ____Extraordinary physical or emotional needs established by a qualified expert |
Name of expert and qualifications:
| (c) | ____Unavailability of suitable families for placement after a diligent search, including: |
| (1) | ____Contact with the tribe’s agent; Date:___________ |
| (2) | ____Search of all county or state listings of available Indian homes and contact with nationally known Indian programs with available placement resources; location of documentation |
| 8. | Explain any extraordinary physical or emotional needs of the children: |
| 9. | Date of Written Notice of Placement Change #1 |
| (d) | Tribe ____________ Name of Person Notified __________ |
Telephone notice given to the Band ____________________
| 10. | Notice of Placement Change #2 |
| (d) | Tribe _____________ Name of Person Notified _________ |
Telephone notice given to the Band ____________________
Consent Documentation for Parents/ Custodian
| 11. | Entry into Custody (Give dates of consent). Was this a PPO or JEO? (Circle one) |
Mother __________
Father __________
Custodian __________
| 12. | Termination of Parental Rights (Give dates of consent). |
Mother __________
Father __________
Custodian __________
Adoption Placement
| 13. | ICWA Preferences (For each preference listed, please indicate the location of records showing contacts with the Band and efforts to comply.) |
| (a) | ____ Member of child’s extended family: ____________________________ |
| (b) | ____ Other members of the Indian child’s tribe: _____________________; |
| (c) | ____ Other Indian families: _________________________________________ |
| (d) | ____ Good Cause for other placement: ______________________________ |
| 14. | Good Cause to Modify ICWA Adoptive Placement Preferences (Please indicate the location of records supporting good cause.) ________________________________________________________________. |
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