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Forms for Adult Foster Care
- AFC Foster Home In Use (71980-257 4/20) (Word) (PDF)
- AFC and CRS Home Safety Checklist (DHS-16-193581 9/21) (PDF)
- AFC Home Program Plan (71980-247 1/19) (Word) ( PDF)
- Evaluation of Agency by AFC Provider (71980-12a 11/10) (Word)(PDF)
- Initial/Relicensing/Alternate Year Data Sheet (71980-234 12/16) (Word) (PDF)
- License Applicant Privacy Rights (72000-2 7/17) (Word) (PDF)
- Program Abuse Prevention Plan - Landscape view (DHS-16-180922 2015) (Word) (PDF)
Additional Forms for Relicensing Visits:
- Adult Foster Home Program (71980-247 1/19) (Word) (PDF)
- AFC Foster Home In Use (71980-257 4/20) (Word) (PDF)
- Alcohol and Drug Use Policy (DHS-16-165250 1/19) (PDF)
- Background Study Tracking Form (71980-236 5/19) (Word) (PDF)
- CFC-AFC-FADS BGS Data Collection Form (DHS 10/19) (PDF)
- Daily Medication Chart (5/08) (Word) (PDF)
- Disaster Plan (71980-182 12/16) (Word) (PDF)
- Emergency Numbers-AFC When to Make a Report to Your Licensor (5/19) (Word) (PDF)
- Fire and Tornado Drill Log (71980-240 12/16) (Word) (PDF)
- Floor and Escape Plan (DHS-2720 3/08) (PDF)
- Grievance Procedure (DHS-16-168251 7/12) (PDF)
- Internal Review of VA Report-SAMPLE (Word) (PDF)
- MJUA Incident Report Form (PDF)
- Program Abuse Prevention Plan - Landscape view (DHS-16-180922 2015) (Word) (PDF)
- Request for a Variance (71980-208 2/11) (Word) (PDF)
- Training Record (71980-216 2/13) (Word) (PDF)
These forms can be used as an index to the file:
- Financial Records (PDF)
- Medical Records (PDF)
- Posted Records (PDF)
- Provider Records (PDF)
- Resident Records (PDF)
- Acknowledgement of Receipt (71980-237 1/19) (Word) (PDF)
- Consent to Share a Bedroom with a Particular Person (71980-57 4/12) (Word) (PDF)
- History and Physical Exam Form (71980-49 3/13) (Word) (PDF)
- Incident Report (71980-62a 5/10) (Word) (PDF)
- Individual Abuse Prevention Plan-IAPP (DHS-16-180924 8/18) (Word) (PDF)
- Individual Resident Placement Agreement (71980-37 4/12) (Word) (PDF)
- Medical-Dental Visit Order Form (71980-96 [P] 11/10) (Word) (PDF)
- Mobility Access Assessment (71980-233 5/16) (Word) (PDF)
- Permission for AFC Provider to Administer Medications (71980-52 4/12) (Word) (PDF)
- Physician's Statement for Medication Administration (71980-220 3/13) (Word) (PDF)
- Placement Packet Checklist (71980-86 1/19) (Word) (PDF)
- Resident Info (71980-36 7/16) (Word) (PDF)
- Resident Rights (DHS 8/18) (Word) (PDF)
- Resident Rights Receipt (71980-251 8/18) (Word) (PDF)
- Resident Monthly Cash Record (71980-27 11/10) (Word) (PDF)
- Vulnerable Adults Act Summary (DHS-306117 3/21) (PDF)
These forms can be used as an index to the file:
- Financial Records (PDF)
- Medical Records (PDF)
- Posted Records (PDF)
- Provider Records (PDF)
- Resident Records (PDF)