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- Community Services
- Foster Care Licensing
- Adult Foster Care
- Forms for Adult Foster Care
Forms for Adult Foster Care
- AFC Foster Home In Use 71980-257 4/20 (PDF)
- AFC Foster Home In Use 71980-257 4/20 (Word)
- AFC and CRS Home Safety Checklist DHS-16-193581 9/21 (PDF)
- AFC Home Program Plan 71980-247 1/19 (PDF)
- AFC Home Program Plan 71980-247 1/19 (Word)
- Evaluation of Agency by AFC Provider 71980-12a 11/10 (PDF)
- Evaluation of Agency by AFC Provider 71980-12a 11/10 (Word)
- Initial/Relicensing/Alternate Year Data Sheet 71980-234 12/16 (PDF)
- Initial/Relicensing/Alternate Year Data Sheet 71980-234 12/16 (Word)
- License Applicant Privacy Rights 72000-2 7/17 (PDF)
- License Applicant Privacy Rights 72000-2 7/17 (Word)
- Program Abuse Prevention Plan - Landscape view DHS-16-180922 2015 (PDF)
- Program Abuse Prevention Plan - Landscape view DHS-16-180922 2015 (Word)
Additional Forms for Relicensing Visits:
Background Studies Forms
- Background Study Tracking Form 71980-236 5/19 (PDF)
- Background Study Tracking Form 71980-236 5/19 (Word)
- CFC-AFC-FADS BGS Data Collection Form DHS 10/19 (PDF)
Miscellaneous Forms
Policy and Program Forms
- Adult Foster Home Program 71980-247 1/19 (PDF)
- Adult Foster Home Program 71980-247 1/19 (Word)
- AFC Foster Home In Use 71980-257 4/20 (PDF)
- AFC Foster Home In Use 71980-257 4/20 (Word)
- Alcohol and Drug Use Policy DHS-16-165250 1/19 (PDF)
- Grievance Procedure DHS-16-168251 7/12 (PDF)
- Internal Review of VA Report-SAMPLE (PDF)
- Internal Review of VA Report-SAMPLE (Word)
- Program Abuse Prevention Plan - Landscape view DHS-16-180922 2015 (PDF)
- Program Abuse Prevention Plan - Landscape view DHS-16-180922 2015 (Word)
Safety Forms
- Disaster Plan 71980-182 12/16 (PDF)
- Disaster Plan 71980-182 12/16 (Word)
- Emergency Numbers-AFC When to Make a Report to Your Licensor 5/19 (PDF)
- Emergency Numbers-AFC When to Make a Report to Your Licensor 5/19 (Word)
- Fire and Tornado Drill Log 71980-240 12/16 (PDF)
- Fire and Tornado Drill Log 71980-240 12/16 (Word)
- Floor and Escape Plan DHS-2720 3/08 (PDF)
- MJUA Incident Report Form (PDF)
Training Forms
These forms can be used as an index to the file:
Care Plan Forms (Reviewed/revised annually)
- Individual Abuse Prevention Plan-IAPP DHS-16-180924 8/18 (PDF)
- Individual Abuse Prevention Plan-IAPP DHS-16-180924 8/18 (Word)
- Individual Resident Placement Agreement 71980-37 10/22 (PDF)
- Individual Resident Placement Agreement 71980-37 10/22 (Word)
Financial Forms
Incident Forms
Intake Forms
- Acknowledgement of Receipt 71980-237 1/19 (PDF)
- Acknowledgement of Receipt 71980-237 1/19 (Word)
- History and Physical Exam Form 71980-49 3/13 (PDF)
- History and Physical Exam Form 71980-49 3/13 (Word)
- Individual Abuse Prevention Plan-IAPP DHS-16-180924 8/18 (PDF)
- Individual Abuse Prevention Plan-IAPP DHS-16-180924 8/18 (Word)
- Mobility Access Assessment 71980-233 5/16 (PDF)
- Mobility Access Assessment 71980-233 5/16 (Word)
- Permission for AFC Provider to Administer Medications 71980-52 4/12 (PDF)
- Permission for AFC Provider to Administer Medications 71980-52 4/12 (Word)
- Physician's Statement for Medication Administration 71980-220 3/13 (PDF)
- Physician's Statement for Medication Administration 71980-220 3/13 (Word)
- Placement Packet Checklist 71980-86 1/19 (PDF)
- Placement Packet Checklist 71980-86 1/19 (Word)
- Resident Info 71980-36 7/16 (PDF)
- Resident Info 71980-36 7/16 (Word)
- Resident Rights DHS 8/18 (PDF)
- Resident Rights DHS 8/18 (Word)
- Resident Rights Receipt 71980-251 8/18 (PDF)
- Resident Rights Receipt 71980-251 8/18 (Word)
- Vulnerable Adults Act Summary DHS-306117 3/21 (PDF)
Medical Forms
- Daily Medication Chart 5/08 (PDF)
- Daily Medication Chart 5/08 (Word)
- History and Physical Exam Form 71980-49 3/13 (PDF)
- History and Physical Exam Form 71980-49 3/13 (Word)
- Medical-Dental Visit Order Form 71980-96 [P] 11/10 (PDF)
- Medical-Dental Visit Order Form 71980-96 [P] 11/10 (Word)
- Permission for AFC Provider to Administer Medications 71980-52 4/12 (PDF)
- Permission for AFC Provider to Administer Medications 71980-52 4/12 (Word)
- Physician's Statement for Medication Administration 71980-220 3/13 (PDF)
- Physician's Statement for Medication Administration 71980-220 3/13 (Word)
Share a Bedroom Form
- Consent to Share a Bedroom with a Particular Person 71980-57 4/12 (PDF)
- Consent to Share a Bedroom with a Particular Person 71980-57 4/12 (Word)