Social Services Forms

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• 2014 Background Study Changes

• 2016-2017 Child Care Assistance Plan

• 2016-2017 MFIP Biennial Service Agreement

• Admission & Arrangements

• Adult Foster Care Self Study Questionnaire

• Adult Mental Health Grant Plan

• AFC Alternate Overnight Supervision Technology Checklist

• AFC Emergency Crisis 5th Bed Variance - General Request

• AFC Emergency Crisis 5th Bed Variance - Initial Request

• AFC Emergency Crisis Respite 5th Bed Variance - Instructions

• AFC Guidelines to Developing Program Abuse Prevention Plan

• AFC Individual Abuse Prevention Plan (IAPP)

• AFC Individual Resident Placement Agreement

• AFC Licensing Checklist - Corporate w/245D

• AFC Licensing Checklist - Family & Corporate w/o 245D

• AFC Licensing Checklist - Family w/245D

• AFC Licensing Checklist - Mental Health Certification

• AFC Program Abuse Prevention Plan

• AFC Program Abuse Prevention Plan - Revised 6/15

• AFC Program Plan

• AFC Training Form

• AFC/Community Residential Setting Home Safety Checklist

• Age Group Definitions

• Agreement between Foster Parents and Placement Agency

• Alcohol & Drug Use Policy

• Allergy Information Form 10-2017

• Annual Training Tracking Record

• Applicant Background Study Letter

• Best Practices Guide - Wading Pools

• Caregiver Tracking Record

• CCAP Direct Deposit

• CCAP Licensed Provider Registration and Acknowledgement

• CFC Annual Evaluation

• CFC Home Study & Licensing Application

• CFC Licensing Checklist

• CFC Licensing Checklist - Corporate Additional

• Change Report Form (for cash assistance and food support) - DHS-2402-ENG

• Child Care Assistance Program Application

• Child Care Provider's Responsibilities and Rights

• Child Foster Care Home Safety Checklist

• Child Foster Care Privacy Notice

• Child Foster Care Self Study Questionnaire

• Child's Information Sheet

• Civil Rights Compliance Plan

• Community Residental Licensing Checklist

• Community Residential Home Safety Checklist

• Consent and Request for Law Enforcement adn Agency Records

• Consent for Release of Information - Abuse & Neglect

• Corporate AFC Background Study Training

• Corporate AFC Licensing Application

• Corporate CFC Licensing Checklist

• Corporate CFC Supplemental Licensing Application

• Crib Safety Inspection

• CRS Relicensing Questionnaire

• Definitions and Requirements for Co-Applicants, Adult Care Givers, Substitutes and Helpers

• Description and Time Lines of Licensing Process

• Developing a Program Abuse Prevention Plan

• DHS Adoption Info Sheet

• DHS Concurrent Planning Info Sheet

• DHS Foster Care Statistics Sheet

• DHS PPAI Info Sheet

• Diapering Area Disinfection

• Discipline Policy

• Elderly Waiver Adult Foster Care Program Plan

• Elderly Waiver Adult Foster Care Program Plan Instructions

• Elderly Waiver Adult Foster Care Recipient Rights

• Elderly Waiver Adult Foster Care Recipient Rights Instructions

• Elderly Waiver Adult Foster Care Service Termination Policy

• Elderly Waiver Adult Foster Care Service Termination Policy Instructions

• Escape Plan

• Exclusions from Licensing

• Fact Sheet

• Fact Sheet - Swimming Pool Risks

• Fact Sheet - Wading Pool Risks

• FADS Individual Service Delivery Plan

• FADS Licensing Checklist

• FADS Program & Policy Information

• FADS Questions & Answers

• FADS Requirements Chart

• Family & Corporate without 245D Questionnaire

• Family AFC & FADS Background Study Training

• Family AFC Licensing Application

• Family AFC w/245D Questionnaire

• Family CFC Supplemental Licensing Application

• Family Disaster Plan

• Fire & Storm Drill Log

• Fire Marshal Links

• Fire Marshall Information Sheet

• General Checklist

• General Licensing Information

• Grievance Procedure

• Guilde to New Crib Standards

• Handout for Applicants and License-Holders

• Health Care Access Services Biennial Plan

• Household Report Form - DHS-2120-ENG

• Individual Fact Sheet

• Infanct Rolling Over Permission Form

• Infant Alternate Sleep Position

• Infant Swaddling Permission Form

• Initial Licensing Cover Letter

• Instructions for completing new DHS application forms

• Instructions for Completing Request for Mental Health Certification

• Is foster parenting right for you?

• Is this business for you?

• Laws Regarding the Completion & Use of Parent Forms

• Liability Insurance Notice

• License Applicant Considerations

• Licensed Family Child Care Providers

• Licensing Application

• Licensing Checklist

• Limited English Proficiency Plan

• Maltreatment of Minors Act

• Maltreatment of Minors Reporting Policy

• Maltreatment of Vulnerable Adult Reporting Policy

• Maltreatment of Vulnerable Adults Act

• MDH Child Care Immunization Form

• MDH Comunicable Disease Rule

• MDH New Immunization Laws

• MEC2 Flowcharts for Providers

• MEC2 Provider Training document

• Medical Mileage Reimbursement Procedure

• Medical Monitoring Equipment Training

• Medical Trip Reimbusement Form

• Mental Health Certification - Attachment A

• Mental Health Certification - Attachment B

• Mental Health Certification Request

• Mental Health Training Requirement

• Minnesota Health Care Programs Change Report Form (for Medical Assistance and Minnesota Care) - DHS-4796-ENG

• MJUA Claim Form

• Monthly Log In/Log Out Sheet

• National Background Check Program video

• NetStudy Instructions - Existing Providers

• NetStudy Instructions - New Providers

• Notice of Privacy Practices

• Notice of Privacy Practices

• Owner Permission for Fire Marshal Inspection

• Owners Permission for Fire Marshall Inspection

• Permission to Administer Medications

• Physician's Report

• Policy for Parental Fees for Out-of-Home Placement

• Preparing for Your Family Day Care Relicensing Visit

• Prospective Foster Family Letter

• Relicensing Cover Letter

• Relocation Checklist

• Relocation of License

• Reporting Policy of Child Abuse and Neglect

• Request for County Burial - asset sheet

• Requirements Regarding Wading & Swimming Pools

• Rule - MN Chapter 9502

• Rule Summary for Parents

• Self Study Questionnaire

• Smoke-free Environment

• Special Family Child Care Homes

• Special Licensing Application

• State Fire Marshall Info Sheet

• Statement of Intended Use

• SUID/AHT Video Training

• Swimming Pool Letter to Parents

• Swimming Pool Permission Form

• Tips for Fire and Storm Drills

• Training Record

• Training Requirements BEFORE Applicant is Licensed

• Training Requirements FOR License Holder

• Travel Authorization

• Unpaid Worksite Agreement

• Varicella (Chickenpox) or Zoster (Shingles) Case Report Form

• Vendor Direct Deposit Form

• Vendored Service Voucher

• Vulnerable Child & Adults Act Plan

• W-9 Request for Taxpayer ID

• Wading Pool Permission Form

• Workers Compensation Compliance Form