INTERSTATE COMPACT ON JUVENILES HOME EVALUATION REPORT HOME REPORT Sending State: Receiving State: Juvenile’s Name: DOB: Placement recommended Case # Placement not recommended Currently in placement PROPOSED PLACEMENT INVESTIGATED: Name: Relationship: Address: Home Phone #: ( ) Work Phone #: ( ) HOME/NEIGHBORHOOD/PEERS (physical description, criminal/gang activity, etc.): FAMILY STATUS (composition, interactions, at-risk family members, attitude, support capabilities, etc.): FAMILY EMPLOYMENT/FINANCIAL RESOURCES (If proposed placement resource works, who will supervise the juvenile): ICJ HOME EVALUATION REPORT Page 1 of 2 REVISED JANUARY 2007 American LegalNet, Inc. www.FormsWorkFlow.com LEGAL HISTORY OF FAMILY (current charges, probation or parole status): PROPOSED PLAN (school/employment, court-ordered conditions, treatment needs): OTHER COMMENTS (recommendations, questions, concerns): REPORTING INSTRUCTIONS: Name: Agency: Address: Telephone # (Investigating worker – printed name) (Investigating worker - signature) (Supervisor – printed name) (Date) (Supervisor - signature) (Date) For ICJ Official use only: Placement approved Placement denied _____ _____________________ (Date) _____________________________________________________ (Compact Official signature) This is the official ICJ Home Evaluation Form as approved by AJCA in August 2003. No state or other governmental entity party to the Interstate Compact on Juveniles may change, alter or otherwise modify any form that has been approved and adopted for use by the Association of Juvenile Compact Administrators. Use of this form for this purpose is optional. (See Rule 3-103: Revision/Modification of Forms) ICJ HOME EVALUATION REPORT Page 2 of 2 REVISED JANUARY 2007 American LegalNet, Inc. www.FormsWorkFlow.com