Licensing forms

This is an online listing of forms maintained by the Department of Human Services.

Forms listed are in the portable document format (PDF).

Forms for adult day centers

  • Application for license (PDF)
  • Center director personnel requirements DHS-5121 (PDF)
  • Document list DHS-5119 (PDF)
  • Floor plan DHS-3613 (PDF)
  • Guidelines for Developing Polices & Procedures (PDF)
  • Orientation Checklist for Participants (PDF)
  • Orientation Checklist for Staff (PDF)
  • Staff ratio requirements DHS-5124 (PDF)
  • Staffing patterns (PDF)
  • Summary of staff information (PDF)
  • Variance request DHS-3141 (PDF)
  • Vulnerable Adults Maltreatment Reporting Policy Form (PDF)
  • Forms for adult foster care

  • FAMILY Adult Foster Care; Family Adult Day Services; Alternate Overnight Supervision Technology Application (PDF)
  • CORPORATE AFC; Community Residential Setting; FADS; Alternate Overnight Supervision Technology Application (PDF)
  • Forms for adult foster care providers serving individuals on Elderly Waiver

  • AFC Recipient Rights – Programs that serve individuals funded by Elderly Waiver (PDF)
  • AFC Service Termination Policy – Programs that service individuals funded by Elderly Waiver (PDF)
  • AFC Program Plan – Programs that serve individuals funded by Elderly Waiver (PDF)
  • Forms for background studies

  • Child Foster Care and Adoption Background Study Identification form (PDF)
  • Consent for release of information from FBI national crime information databases to private child placing agency (required for background studies from private child placing agencies only) (PDF)
  • Supplement to Recommendation Form – DHS 3324 (CFC, AFC, FADS) (PDF)
  • Consent for release of information from child abuse and neglect registry when background study subject resided outside Minnesota within last five years DHS-7610 (PDF)
  • DHS Guardian/Conservator Background Study Form (PDF)
  • Forms for child care centers

  • Forms for child care centers are now located on the updated Licensed Child Care Centers web page.

  • Forms for child foster care

  • Minnesota Adoption and Child Foster Care Application (3-17) (PDF)
  • Minnesota Corporate Child Foster Care Application (3-17) (PDF)
  • Parental Consent for Swaddling (7-13) (PDF)
  • Physicians Directive for Infant Sleep Position (7-13) (PDF)
  • Forms for family child care

    SUDDEN UNEXPECTED INFANT DEATH (SUID) AND ABUSIVE HEAD TRAUMA (AHT) TRAINING FOR FAMILY CHILD CARE

    SUID/AHT Requirements and Video Links

    TRAINING DOCUMENTS

  • Printing Instructions for your KCF/Develop learning record (4-17) (PDF)
  • PROVIDER QUESTIONS

  • Provider questions
  • Previous questions/answers
  • OTHER DOCUMENTS

  • Poisonous Plants and Family Child Care Guidance (8-16) (PDF)
  • Child Care Immunization Form (12-13) (PDF)
  • Dear Parent Swimming Letter (5-12) (PDF)
  • Family and Group Family Child Care Rule Summary for Parents (2/15) (PDF)
  • Family Child Care Admission and Arrangements (11-13) (PDF)
  • Family Child Care Liability Insurance Notice to Parents/Guardians (7-13) (PDF)
  • Family Child Care Licensing Checklist (10-16) (PDF)
  • FCC Application (2-24-14) (PDF)
  • Monthly Crib Inspection Form (6-14) (PDF)
  • Parental Consent for Swaddling (7-13) (PDF)
  • Physicians Directive for Infant Sleep Position (7-13) (PDF)
  • Optional form for parent statement; infant less than six months of age regularly rolling over (3-14) (PDF)
  • Special FCC Application (2-24-14) (PDF)
  • Swimming Pool Fact Sheet and Consent (5-13) (PDF)
  • Swimming Pool Permission Form (5-13) (PDF)
  • Wading Pool Fact Sheet Letter and Permission Form (5-12) (PDF)
  • Forms for Family Systems programs

  • Family Systems Licensor Packet
  • Forms for Home and Community-Based Services (HCBS)

  • Program Policies and Forms
  • Self-monitoring Checklists (PDF)
  • Death or Serious Injury Report Forms and FAX Cover Sheet
  • Application Information and Forms
  • Forms for mental health and chemical health programs

    All Programs

  • Variance request form DHS-3141 (PDF)
  • Sample – Vulnerable Adults Maltreatment Reporting Policy form (PDF)
  • Sample – Maltreatment of Minors Reporting Policy form (PDF)
  • License Application Forms

  • Application for Rule 29 Certification (PDF)
  • Chemical Dependency Treatment – Rule 31, DHS-7118 (PDF)
  • Children’s Residential Treatment Facilities application process
  • Detoxification Programs – Rule 32, DHS-7118 (PDF)
  • Intensive Residential Treatment or Crisis Services DHS-7118 (PDF)
  • Independent Living Assistance for Youth Services DHS-7118 (PDF)
  • Children’s Residential Treatment Facilities

  • • CRF - Screening forms for CRF programs
  • • CRF – Critical Incident Reporting Form for Children (PDF)
  • Information Regarding Crib Standards and Compliance (3-13) (PDF)
  • DHS Monthly Crib Safety Inspection form (12-14) (PDF)
  • • CRF – Self-Monitoring Checklist
  • For a current Children’s Residential Facility checklist, contact DHS Licensing or call
  • 651-431-6500.
  • Independent Living Assistance for Youth

  • Information Regarding Crib Standards And Compliance (3-13) (PDF)
  • DHS Monthly Crib Safety Inspection form (12-14) (PDF)
  • Intensive Residential Treatment Services

    [Includes Crisis Stabilization (CS) and Eating Disorders (ED) Certification]

  • • IRTS/CS/ED – Critical Incident Reporting Form for Adults (1-13) (PDF)
  • • Sample – IRTS/CS/ED – Referral form (PDF)
  • • IRTS/CS/ED – Self-monitoring checklist (PDF)
  • Minnesota Sex Offender Programs

  • • Rule 26 – Vulnerable Adult Determination Form (11-08) (PDF)
  • Mental Health Clinics and Centers

  • Rule 29 – Satellite Location form (PDF)
  • Rule 29 – Self monitoring checklist (PDF)
  • Chemical Dependency Treatment Programs

  • Rule 31 - Electronic Records Form (PDF)
  • Rule 31 Outpatient - Vulnerable Adult Determination Form (6-08) (PDF)
  • Rule 31 Example Comprehensive Assessment Summary (7-15) (PDF)
  • Rule 31 Example Comprehensive Assessment (10-10) (PDF)
  • Rule 31 Example Initial Services Plan (10-10) (PDF)
  • Rule 31 Example Progress Note and Treatment Plan Review (10-10) (PDF)
  • Rule 31 Example Individual Treatment Plan (10-10) (PDF)
  • Rule 31 Example Discharge Summary (2-11) (PDF)
  • • Rule 31 – Self-monitoring checklist (PDF)
  • Rule 31 – Forms used only by Programs serving Clients with their Children

  • Information Regarding Crib Standards and Compliance (3-13) (PDF)
  • DHS Monthly Crib Safety Inspection form (12-14) (PDF)
  • Detoxification Services

  • • Rule 32 – Variance Agreement for use of Law Enforcement in Detox Programs (PDF)
  • • Rule 32 – For a current Detoxification Program checklist, contact DHS Licensing
  • or call 651-431-6500.
  • Forms for private child placement agencies

  • Application for license DHS-7118 (PDF)
  • For more information about licensing forms, call (651) 431-6500; or fax to (651) 431-7643. TTY/TDD users can call the Minnesota Relay at 711 or (800) 627-3529. For the Speech-to-Speech Relay, call (877) 627-3848.

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