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Questionner for Relative Adoption Applicants

ICAB applicant questionner for relative adoption

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I.

March 6, 2018

Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

Issue
Date
Doc. Code

2

ICAB – RELAU – F
2007 – 001

Identifying Information on the Child/ren:

1. Name of the
child/ren:

Name

1.
2.
3.
4.
2. Name
of
Birthparents

Date of Birth

___________
___________
___________
___________

Birth Status

___________
___________
___________
___________

__________
__________
__________
__________

󠆩󠇗 ____________________

Birthmother: 󠆩󠇗 N.A
Birthfather: 󠆩󠇗 N.A

󠆩󠇗 ____________________
󠆩󠇗 ____________________

Birthmother: 󠆩󠇗N.A

3. Address of the
Birthparents

the Birthfather: 󠆩󠇗 N.A

󠆩 󠆩󠇗_____________________

3. Occupation of the Birthfather: 󠆩 󠆩󠇗 N.A
Birthparents
Birthmother: 󠆩󠇗 N.A
4. Income of the Birthfather: 󠆩 󠆩󠇗 N.A
Birthparents
Birthmother: 󠆩󠇗 N.A
Name
5. Sibling/s of the
1. ____________
child/ren to be
2. ____________ 󠆩
adopted
3. ____________ 󠆩
(including
4. ____________ 󠆩
child/ren
for
5. ____________
adoption)

󠆩󠇗 ____________________
󠆩󠇗 ___________________
󠆩󠇗 ___________________
󠆩󠇗 ___________________
Date of Birth
____________
____________
____________ 󠆩
____________ 󠆩
____________

Gender
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯
󠆩 󠆩󠇗M 󠆩󠇗F󠇯
󠆩 󠆩󠇗M 󠆩󠇗F󠇯
󠆩 󠆩󠇗M 󠆩󠇗F󠇯

6. Name
of
the
Guardian/Child’s 󠆩 _______________________________________________
Custodian
Relationship to the Child: ____________________

_______________________________________________
Street
Mun/City
Province

Current
and No.
Complete address

Page 1 of 7

Inter-Country Adoption Board (ICAB)

of the child/ren
and
his/her
custodian
7. Contact
Information
of
Landline:
the child/ren and
his/her custodian

March 6, 2018

Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

Issue
Date
Doc. Code

2

ICAB – RELAU – F
2007 – 001

Mobile

8. Attitude of prospective adoptive child/children towards his/her/their being
adopted. (If applicable, depending on age and level of maturity of
prospective adoptive child/children).

9. Attitude of child/ren 󠆩 in 󠆩 the 󠆩 home 󠆩 of 󠆩 PAP’s 󠆩 with 󠆩 respect 󠆩 to 󠆩 the 󠆩 adoption
project.
NAME

DATE OF BIRTH

OCCUPATION

STATUS

REMARKS

____________

_______________

___________󠆤 󠆩󠇗SINGLE 󠆩 󠆩󠇗MARRIED

________________

____________

_______________

___________󠆤 󠆩󠇗SINGLE 󠆩 󠆩󠇗MARRIED

________________

____________

_______________

___________󠆤 󠆩󠇗SINGLE 󠆩 󠆩󠇗MARRIED

________________

____________

_______________

___________󠆤 󠆩󠇗SINGLE 󠆩 󠆩󠇗MARRIED

________________

____________

_______________

___________󠆤 󠆩󠇗SINGLE 󠆩 󠆩󠇗MARRIED

________________

10.Is/Are the parents of the child/ren in touch (visit, write, phone calls) with
the prospective adoptee/s?

Page 2 of 7

Inter-Country Adoption Board (ICAB)

Issue
Date
Doc. Code
Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

II.

March 6, 2018

2

ICAB – RELAU – F
2007 – 001

Identifying Information on Prospective Adoptive Parents (PAPs)
Male PAP

Female PAP

11. Name:
12.Date of Birth:
13.Address:

󠇗 Owned

󠆩

󠆩Rented

___________________________________________________
No.
Street
Mun/City
Country
Contact No.

14. Place of Birth:
15.Citizenship:
16. Date of Marriage:
17.Place of Marriage:
18.Divorce History, if
any. (Please
include reason for
divorce.)
19.Education:
20.Occupation:
21.Employer:
22.Annual Income:
23.Liabilities:
24.Religion:
25.Biological
child/ren: (Name,
Date of Birth, Sex,
health condition,
educational

NAME
1.
2.
3.
4.

GENDER

___________
___________
___________
___________

󠆩󠇗M
󠆩󠇗M
󠆩󠇗M
󠆩󠇗M

󠆩󠇗F󠇯
󠆩󠇗F󠇯
󠆩󠇗F󠇯
󠆩󠇗F󠇯

Page 3 of 7

AGE
______
______
______
______

HEALTH
󠆩󠇗 󠆩 󠆩Normal
󠆩󠇗 󠆩 󠆩Normal
󠆩󠇗 󠆩 󠆩Normal
󠆩󠇗 󠆩 󠆩Normal

󠆩󠇗
󠆩󠇗
󠆩󠇗
󠆩󠇗

Special
Special
Special
Special

Condition
Condition
Condition
Condition

Inter-Country Adoption Board (ICAB)

attainment, short
description of
personality)
NAME
26.Adopted child/ren:
1.___________
(name, date of 2. __________
birth, country of 3. ___________
origin,
date
of 4. ___________
placement
and
finalization
of
adoption,
health,
educational
attainment, short
description
of
personality)
27. Attitude of their Remarks:
biological/adopted
child/ren
towards
adoption
NAME
28. Other
individuals
1.____________
living in the home 2. ___________
(please indicate the 3. ___________
relationship
to 4. ___________
applicants, attitude
towards adoption
plans, permanently
or
temporarily
residing with the
PAPs, contribution,
if any to the family
income)
II.

GENDER
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯

GENDER
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯
󠆩󠇗M 󠆩󠇗F󠇯

March 6, 2018

Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

Issue
Date
Doc. Code

2

AGE
______
______
______
______

ICAB – RELAU – F
2007 – 001

HEALTH
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition

AGE

HEALTH

______
______
______
______

󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Conditio
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition
󠆩󠇗 󠆩 󠆩Normal 󠆩󠇗 Special Condition

History
Male PAP

29. Health History

Female PAP

I do not fall within the
prohibited condition as
provided for by ICAB Board
Resolution 13-001 Series of
2013

I do not fall within the
prohibited condition as
provided for by ICAB Board
Resolution 13-001 Series of
2013

Page 4 of 7

Inter-Country Adoption Board (ICAB)

󠇗
Remarks:

Remarks:
󠇗 N.A
󠇗 Condition
󠇗 Medication

33. CA/FAA (Reason for
use of out of state
FAA)

2

ICAB – RELAU – F
2007 – 001

󠇗
Remarks:

30. Sexual/Physical
󠇗 N.A
Abuse
History/ 󠇗 with abuse history
Addiction
to
Pornography, if any Remarks:
31. Criminal History, if
󠇗 N.A
any
󠇗 with criminal history
32. Psychological Health

March 6, 2018

Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

Issue
Date
Doc. Code

Name:
Address:

Remarks:

34. Reason/s or Motivation to adopt a Child/ren.

Page 5 of 7

󠇗 N.A
󠇗 with abuse history
Remarks:
󠇗 N.A
󠇗 with criminal history
Remarks:
󠇗 N.A
󠇗 Condition
󠇗 Medication

Inter-Country Adoption Board (ICAB)

March 6, 2018

Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

Issue
Date
Doc. Code

2

ICAB – RELAU – F
2007 – 001

35. Description of the degree of bonding between the prospective adoptive
parents (PAPs) and the prospective adoptive child/children. (To include,
among others, ways and means of nurturing relationship (letters, phone
calls, greeting cards, etc.), visits to the Philippines (who visited, when,
duration of stay in the Philippines, what they did together with the
prospective adoptive child/children)

36. Parenting Experience with Children.

37. Attachments: Send at least one copy for each of the following:
1. Copy

of the Birth Certificate of PAPs
2. Copy of the Marriage Certificate of PAPs
3. Copy of the Birth Certificate of the child/ren
4. Copy of the Birth Certificate of the birthparent/s or pertinent persons to
establish the relationship of the child/ren with the PAPs
5. Family Genogram
6. Recent close up pictures of the PAPs (4R)
7. Recent close up pictures of the existing child/ren in the families with the
PAPs
8. Recent photos/videos of the home of prospective adoptive parents (PAPs)

Page 6 of 7

Inter-Country Adoption Board (ICAB)

March 6, 2018

Revision
No.

QUESTIONNAIRE FOR RELATIVE
ADOPTION APPLICANTS (QRAA)

Issue
Date
Doc. Code

2

ICAB – RELAU – F
2007 – 001

I/WE certify that the information provided herein are true under the penalty of
perjury.

__________________________
Name and Signature of Male PAP
Date:

____________________________
Name and Signature of Female PAP
Date:

_________________________________
Name and Signature of the Social Worker
Position:
CA/FAA:
Affiliate/Cooperating Agency:
Date:

Page 7 of 7
 
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