Provider Forms

  • Cash Resource Procedures - State procedures to be used when the license holder manages a resident’s funds
  • Employee List - To document current employees and any changes in employment in the facility
  • Fire Drill Log - To document provider’s fire drills
  • Foster Care Medical Monitoring Equipment Training and Skills Form - To be used for verification that the license holder has received appropriate training when a resident relies on medical equipment to sustain life or monitor a medical condition that verifies
  • Grievance Policy Sample - Use this sample to develop an appropriate grievance procedure that residents and/or their legal representatives may use to bring forth issues regarding the care of a resident. Submit the completed policy to licensing. The applicant must develop the policy for specific use within the AFC home; although the sample language may be used, a print of this sample will not be accepted
  • Incident Report - Provider completes when an accident occurs
  • Individual Abuse Prevention Plan - This plan is specific to each resident and assesses the resident and the physical environment of the licensed facility. The license holder should determine how the risk of harm will be reduced in each area of the assessment. This form must be reviewed annually by the license holder and updated as the needs of the resident changes
  • Individual Adult Foster Care Background Studies Training - Link to DHS website for providers to be trained on entering background study information on NETStudy
  • Individual Resident Placement Agreement - This agreement must be completed at the initial placement and reviewed annually specifying the terms of the foster care services that will be provided to the resident
  • Medication Assistance for Adult Foster Care Residents - State procedures to follow when the license holder will be providing a resident assistance with medication
  • Mobility Access assessment - To be completed at initial placement and reviewed annually when a resident has difficulties with mobility or a seizure disorder.
  • Permission to Administer Medication - This form is to be signed by the resident and/or resident’s legal representative to give the provider permission to administer medications to the resident
  • Physical Exam Form for Residents - The license holder must ensure that each resident is examined by a physician no more than 30 days before or within 3 days after a placement in the facility. Transfer records from a health care facility licensed by the Department of Health may be substituted for this requirement
  • Placement Record - To document resident placements
  • Program Abuse Prevention Plan - This plan is completed by the license holder by assessing the residents and physical environment of the licensed facility and surrounding grounds. The license holder should determine how the risk of harm will be reduced in each area of assessment. This form must be reviewed annually by the licensed holder and updated as the needs of the residents change. This plan should not contain resident names or identifying information
  • Program Plan - Complete the plan by determining what, if any, services will be provided to the residents that exceed the standard services required by Rule 203
  • Guidelines to Developing a Program Abuse Prevention Plan
  • Reporting Maltreatment of Vulnerable Adults Policy Sample - Use this sample to develop an appropriate policy that guides caregivers, residents and/or their legal representatives in reporting suspected or known maltreatment of a vulnerable adult. Submit the completed policy to licensing. The applicant must develop the policy for specific use within the AFC home; although the sample language may be used, a print of this sample will not be accepted
  • Resident’s Rights - Rights of the resident that must be signed by the resident and resident’s legal representative on an annual basis
  • Rule 203—Family and Corporate Adult Foster Care Licensing Checklist - Review for compliance with licensing regulations
  • Training Log - Caregivers with 0 to 5 years of licensure / experience are required to complete 12 hours of training annually. Caregivers with 6-plus years of licensure / experience are required to complete 6 hours annually
  • Substance Abuse Policy Sample - Use this sample to develop an appropriate policy that prohibits the use or abuse of chemicals that impair the caregiver’s ability to provide care. The applicant must develop the policy for specific use within the AFC home; although the sample language may be used, a print of this sample will not be accepted