DHS Program Resources Licensing

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.

Common Websites

Revisor website
Licensing Information Lookup (LIL)
Electronic Licensing Monitoring System (ELMS)
NETStudy 2.0
TrainLink - Register for DHS-offered trainings

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)
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

Licensor Processes Guide (PDF) (11-23)
Commissioner Access Letter (PDF) (1-25)
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)
Application Tracking Log PDF) (11-22)
Foster Care Medical Monitoring and Equipment Training and Skills Form (not used by CRS)
Notice of Incomplete Application (DOCX) (45 day letter)
Guidance for closing an inactive family child foster care, family adult foster care, or family adult day services license (PDF)
Sample letter – Closing an inactive license (DOCX) (11-24)

Variance Forms

Variance Request Form (General) (PDF) (10-23)
Dual License Variance (PDF) (7-22)

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

Corporate Application - AFC; Community Residential Setting; FADS; Alternate Overnight Supervision Technology (PDF) (1-26)

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)