MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION EMPLOYER REFERENCE QUESTIONNAIRE
FROM:	Resource Licensing Worker	Telephone Number	Date
Address
City	State	Zip Code
Agency Contact	Office Hours
If you have questions or need assistance in completing this form, please call the Resource Licensing Worker listed above.
TO:	Employer Name
Address (Street and Number)
City	State	Zip Code
RE:	Applicant
The above named family has applied to the Missouri Children’s Division to serve as foster/relative/adoptive parents. In order to complete our assessment of their application, it is necessary that we obtain information about the family. Please complete the information below in as much detail as possible and attach a separate sheet if necessary. Any information you can give us which will help us in evaluating this application will be appreciated. Please reply at your earliest convenience. Please use the enclosed envelope for your response.
Company Name	Telephone Number
Address
I. Length of Time Employed	II. Type of Employment	III. Monthly Earnings
IV. # of Hours per Week	V. Shift Worked: Day Shift (8 am to 5 pm) Evening Shift (5 pm to 12 am) Night (12 am to 8 am)
VI. Prospects for continued Employment Advancement
VII. Employer's evaluation of the applicant's peer relationships, work record, character, personality:
VIII. Does the Employer know the applicant well enough to give us information regarding his/her home life, reputation in the community, capacity for caring for a child? Yes No If yes, please explain:
Form Completed by: (Employer's Signature)	Telephone Number	Date
Print/Type Employer’s Name: