County Partnership Licensor Library
This Licensor Library contains forms, documents and resources used for adult foster care (AFC), child foster residence settings (CFRS), community residential settings (CRS), and family adult day services (FADS). These forms were previously located on the Family Systems webpage. The Shared Forms section includes forms and resources used by all service types (AFC, CFRS, CRS and FADS). Forms specific to one service type are located under that service type heading.
Quick Links
Revisor website
Licensing Information Lookup (LIL)
Electronic Licensing Monitoring System (ELMS)
NETStudy 2.0
TrainLink - Register for DHS-offered trainings
Licensor Link newsletter
Triage
County Partnership Triage: 651-431-4515
HCBScountypartnership.dhs@state.mn.us
Shared Forms
3324/Closing/Extension/PIF/Withdrawal
3324 – License Recommendation - Foster Care - CFRS AFC CRS FADS
Appropriate Action to Take at the Expiration of a License Chart (PDF) (9-25)
License Extension Request or Closure Pending Investigation (11-21)
Preliminary Information Form (PIF) – all license types
Withdrawal of License Application (PDF) (3-24)
Sample letter – Closing an inactive license (DOCX) (AFC/CFRS only) (11-24)
Complaint/Correction Order/Licensing Action
Complaint Log (PDF) (11-22)
A22 Correction Order (PDF) (12-22)
Foster Care Licensing Action Manual (PDF) (10-21)
Licensing Actions (2-20)
Licensing Intake Complaint Form (10-13)
Notice of Privacy Practices (PDF) (10-17)
Recommendation for Licensing Action (PDF) (6-24)
Request for Temporary Provisional Foster Care License (12-17)
Fire Marshal Forms and Information
Property Owner Permission for Fire Marshal Inspection (PDF) (1-26)
Request for Fire Inspection or Reinspection (7-26)
State Fire Marshal Website – Child Care/Foster Care Inspections
Minnesota Interagency Agreement Between the Departments of Public Safety and Human Services (PDF) (7-23) – for use by DHS
General Forms and Resources
Application Tracking Log (11-22)
Commissioner Access Letter (PDF) (8-26)
Data Privacy Guidelines
Emergency Escape Plan and Procedures (PDF) (10-22)
Foster Care FAQ – Licensing Previously Licensed Programs (PDF) (8-21) (not used by CRS)
Foster Care Medical Monitoring and Equipment Training and Skills Form (not used by CRS)
Guidance for closing an inactive family child foster care, family adult foster care, or family adult day services license (PDF)
Licensor Processes Guide (PDF) (11-23)
Notice of Immediate Background Study Action Form (PDF) (8-26)
Notice of Incomplete Application (DOCX) (45 day letter)
Sample letter – Closing an inactive license (DOCX) (11-24)
Work comp compliance – Certificate of Workers’ Compensation Compliance
Variance Forms
Variance Request Form (General) (PDF) (10-23)
Dual License Variance (PDF) (7-22)
Foster Care/CRS Age or Overnight Supervision Variance Request (3-24)
Adult Foster Care
Applications
Application – Corporate AFC; Community Residential Setting; FADS; Alternate Overnight Supervision Technology (PDF) (1-26)
Application – Family Adult Foster Care; Family Adult Day Services; Alternate Overnight Supervision Technology (PDF) (1-26)
Supplement to Application – FAMILY Adult Foster Care (PDF) (11-25)
Background Studies
General Request for Reconsideration of a Disqualification (PDF) (1-24)
Checklists
Alternate Overnight Supervision Technology Checklist (PDF) (3-25)
Home Safety Checklist – Adult Foster Care/Community Residential Setting (PDF) (9-21)
Adult Foster Care Capacity of Five: Supplementary Checklist (PDF) (9-24)
Licensing Checklist – Family and Corporate Adult Foster Care without HCBS (PDF) (3-26)
Licensing Checklist – Family Adult Foster Care with HCBS Licensing Checklist (PDF) (3-26)
Emergency Crisis Capacity Variances
Initial License Holder Request for Crisis Capacity Variance (PDF) (11-18)
Initial County Request for Crisis Capacity Variance (PDF) (11-18)
General License Holder Request for Crisis Capacity Variance (PDF) (11-18)
General County Request for Crisis Capacity Variance (PDF) (11-18)
General Documents
AFC Exemptions under Dually Licensed AFC and 245D HCBS Programs (PDF) (4-14)
Vulnerable Adult Act Summary (PDF) (9-22)
Family Adult Foster Care Licensing – Policy Clarification (PDF) (8-21)
Mental Health Certification (corporate AFC only)
Instructions for Completing a Request for a Mental Health Certification (10-14)
Attachment A: Mental Health Certification (PDF) (7-15)
Attachment B: Mental Health Certification (PDF) (3-13)
Mental Health Certification Licensing Checklist (PDF) (9-12)
Request for Mental Health Certification (PDF) (10-14)
Policies/Plans/Required Forms
Adult Foster Care Program Plan (PDF)
Adult Foster Care Resident Rights (DOCX) (8-18)
Drug and Alcohol policy (PDF) (11-22)
Grievance procedure sample for Adult Foster Care (PDF)
Individual Abuse Prevention Plan (PDF) (8-18)
Individual Resident Placement Agreement (PDF) (12-13)
Program Abuse Prevention Plan (6-26)
Adult Foster Care Reference Letter Sample (PDF) (5-18)
Other Variances
Ceiling Height Variance Request Form (PDF) (5-17)
Child Foster Residence Setting
Application/Home Study
Application – Child Foster Residence Setting (PDF) (1-26)
Home Study Assessment for Child Foster Residence Setting (PDF) (6-24)
Home Study Assessment Update for Corporate Child Foster Care (PDF) (12-15)
Checklists
Child Foster Residence Settings Licensing Checklist (PDF) (11-25)
Home safety checklist (DHS-8313) (PDF) (6-24)
Policies/Required Forms
Foster Parent Agreement Form (DHS-0139) (PDF) (7-24)
Summary of child foster care responsible agency requirements (PDF) (11-17)
Annual Evaluation of Licensed Foster Home (PDF) (10-22)
Child Foster Residence Setting Fact Sheet (PDF) (7-24)
Discipline policy sample (PDF) (5-18)
Drug and Alcohol Policy (PDF) (11-22)
Statement of Intended Use (PDF) (1-15)
Training
Mental Health and Fetal Alcohol Spectrum Disorders Training for Child Foster Care (PDF) (4-21)
Normalcy and Reasonable Prudent Parent Standard (Video) (6-18)
Variances
Variances to Minnesota Rule (PDF) (1-24)
Community Residential Settings
Applications/General Forms
Checklists
Home Safety Checklist – Adult Foster Care/Community Residential Setting (PDF) (9-21)
Licensing Checklist – Community Residential Setting (PDF) (11-25)
Adult Foster Care Capacity of Five – Supplementary Checklist (PDF) (9-24)
Mental Health Certification
Instructions for Completing a Request for a Mental Health Certification (10-14)
Attachment A: Mental Health Certification (PDF) (7-15)
Attachment B: Mental Health Certification (PDF) (3-13)
Mental Health Certification Licensing Checklist (PDF) (9-12)
Request for Mental Health Certification (PDF) (10-14)
Policies/Plans/Required Forms
Program Abuse Prevention Plan (6-26)
Vulnerable Adults Act Summary (PDF) (9-22)
Remote Overnight Supervision
Remote Overnight Supervision Policies and Procedures (PDF) (2-25)
Informed Consent for Remote Overnight Supervision (PDF) (2-25)
Remote Overnight Supervision Provider Notification to County (PDF) (2-25)
Remote Overnight Supervision Physical Presence Response Drill Log (PDF) (2-25)
Variances
Initial License Holder Request for Crisis Capacity Variance (PDF) (11-18)
Initial County Request for Crisis Capacity Variance (PDF) (11-18)
General License Holder Request for Crisis Capacity Variance (PDF) (11-18)
General County Request for Crisis Capacity Variance (PDF) (11-18)
General variance form (PDF) (10-25)
Family Adult Day Services (FADS)
Applications
Application – Corporate AFC; Community Residential Setting; FADS; Alternate Overnight Supervision Technology (PDF) (1-26)
Application – Family Adult Foster Care; Family Adult Day Services; Alternate Overnight Supervision Technology (PDF) (1-26)
Checklists
Licensing Checklist – FADS (PDF) (11-25)
Home Safety Checklist (FADS in AFC home only) (PDF)
Other Forms
Individual Service Delivery Plan – FADS (PDF) (9-22)
Policy and Program Information – FADS (PDF) Requirement Chart – FADS (PDF) (12-13)
Questions and Answers – FADS (PDF) (7-12)
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