Family Systems
Dear Licensing Worker:
We have prepared and organized documents that are commonly used in licensing for family systems programs. The documents are divided up by general licensing information, by specific programs, and by background studies information.
General Licensing
Family Child Care
Child Foster Care
Adult Foster Care
Family Adult Day Services
Background Studies
Family Systems Applications
Below are the Rules and Statutes that are pertinent to each family systems program. We suggest that you visit the Revisor’s website at https://www.revisor.leg.state.mn.us/pubs/ and print a copy of each Statute and Rule applicable to the program(s) you license.
County Agencies - Minnesota Rule, parts 9543.0010 to 9543.0150
Family Child Care
Minnesota Statutes, Chapter 245A (Human Services Licensing Act)
Minnesota Statutes, Chapter 245C (Human Services Background Studies Act)
Minnesota Rules, parts 9502.0300 to 9502.0445 (Rule 2)
Child Foster Care
Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Rules, parts 2960.3000 to 2960.3340
Adult Foster Care
Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Rules, parts 9555.5050 to 9555.6265 (Rule 203)
Family Adult Day Services
Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Statutes, section 245A.143
Private Child Placing Agencies
Minnesota Rules, parts 9545.0755 to 9545.0845 – Rule 4
Minnesota Rules, parts 9543.0010 to 9543.0150 – Rule 13 – for those private agencies that license Child Foster Care Programs
Child Foster Care
Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Rules, parts 2960.3000 to 2960.3340
General Licensing – Section A
A2 Family Child Care Phone List (6-21) (PDF)
A5 Foster Care Licensor Processes Guide (4-21) (PDF)
A6 Foster Care Licensor Resources (4-21) (PDF)
A8 Data Privacy Guidelines DHS-8317 (9-22) (PDF)
A13 Considerations for Less than a Two Year License (3-08) (PDF)
A14 Appropriate Action to Take at the Expiration of a License DHS-8409 (4-23) (PDF)
A15a Family Child Care License Extension Request/Closure Pending Investigation Form (1-19) (PDF)
A15b License Extension Request or Closure Pending Investigation Foster Care Form DHS-8153 (11-21)
A16 Request for Temporary Provisional License DHS-8290 (7-22) (PDF)
A17 Foster Care Dual Licensure Variance Request DHS-8289 (7-22)
A18 Variance Request Form – Family Systems (7-21) (PDF) A19 Variance Request Form DHS-3141 (10-23) (PDF) A20 Correction Orders/ Reconsideration of Correction Orders – General Information (1-07) (PDF)
A21 Correction Order – Sample (10-12) (PDF)
A22 Correction Order- Form (3-19) (PDF)
A23 Complaint Log DHS-8362 (11-22) (PDF)
A24 Application Tracking Log DHS-8360 (11-22) (PDF)
A25 Licensing Actions (2-20) (PDF)
A26 Negative Action Recommendation Sample Letters:
- A26a Recommendation for a Denial of a FCC License (3-16) (PDF)
- A26b Sample Recommendation for a Temporary Immediate Suspension of a Family Child Care License (2-19) (DOC)
- A26c Sample Recommendation for a Conditional of a Family Child Care License (2-19) (DOC)
- A26d Recommendation for a Revocation for FCC License (3-16) (PDF)
- A26e Sample Recommendation for a Fine of a Family Child Care License (2-19) (DOC)
- A26f Sample Recommendation for Denial of Family Child Care License (2-19) (DOC)
A27 Temporary Immediate Suspension Protocol (3-08) (PDF)
A28 Certificate of Personal Service Sample DHS-8433 (4-23) (PDF)
A29 Comparison of Requirements by Rule (7-14) (PDF)
A30a – Licensing Action Notification Letter Samples for Family Child Care 5-19 (DOCX)
A31 Alcohol and Drug Use Policy-Sample Family Child Care DHS-7735 (6-18) (PDF)
A32 Grievance Procedure Sample Family Child Care DHS-7740 (6-18) (PDF)
A33 Fire Marshal Links to Forms and Information
- A33a Owners Permission for Fire Marshal Inspection (2-18) (PDF)
- A33b Request for Fire Inspection or Reinspection DHS-7786 (6-23) (PDF)
- A33c State Fire Marshal – Child Care/Foster Care Inspections link
- A33d Minnesota Interagency Agreement Between the Departments of Public Safety and Human Services DHS-8458 (7-23) (PDF)
A34 Child Foster Care Home Safety Checklist DHS-8313 (1-24) (PDF)
A35 Child Foster Care Home Safety Checklist Guidance DHS-8474 (11/23) (PDF)
A36 Home Safety Checklist - Adult Foster Care/Community Residential Setting (9-21) (PDF)
A37 Licensing Intake Complaint Form DHS-8366 (11-22) (PDF)
A38 Chemical Use Problems Family Child Care and Child Foster Care
- A38a FCC Chemical Use Problems– Guidelines & Process (8-19) (PDF)
- A38b Chemical Use Problems – Variance Request Form FCC/CFC DHS-8405 (3/23) (PDF)
- A38d Risk of Harm Assessment and Recommendation – FCC & CFC (8-19) (DOCX)
- A38e CFC Chemical Use Problems– Guidelines & Process (8-22) (PDF)
A39 Commissioner Access Letter (10-21) (PDF)
A40 Emergency Escape Plan for Foster Care DHS-8341 (10-22) (PDF)
A41 Drug and Alcohol Policy sample – Foster Care DHS-8364 (11-22) (PDF)
A42 Foster Care Notice of Incomplete Application (DOCX)
A43 Foster Care FAQ – Licensing Previously Licensed Programs (8-21) (PDF)
A44 Foster Care Licensing Action Manual (10-1) (PDF)
A45 Guidance for closing an inactive family child foster care, family adult foster care, or family adult day services license (PDF)
Family Child Care – Section B
B1 Unlicensed Family Child Care Letter – Sample (2-19) (DOCX)
B2 Maltreatment of Minors Mandated Reporting - Family Child Care DHS-7634C (3-21) (PDF)
B3 Exclusions from Licensure Family Child Care DHS-7739 (6-18) (PDF)
B4 Age Group Definitions Family Child Care DHS-7734 (6-18) (PDF)
B7a Family Child Care Enrollment Form DHS-DHS-7934 (7-19) (PDF)
B8 Monthly Crib Safety Inspection Form DHS-7743 (6-14) (PDF)
B10 Wading Pool Best Practices Form Family Child Care DHS-7668B (3-18) (PDF)
B11 Wading Pools Risks Family Child Care DHS-7749D (6-18) (PDF)
B12 Swimming Pool Risks Family Child Care DHS-7749B (6-18) (PDF)
B13 Wading Pool Permission Form Family Child Care DHS-7749C (6-18) (PDF)
B14/15 Swimming Pool Permission Form Family Child Care DHS-7749A (6-18) (PDF)
B18 Prohibition Letters (6-12) (PDF)
B19 Prohibition Flowchart page 1 (3-09) (PDF)
B20 Prohibition Flowchart page 2 (3-09) (PDF)
B21 Directive for Alternative Infant Sleep Position DHS-7216 (1-24) (PDF)
B22 Swaddling Consent for an Infant DHS-7218 (1-24) (PDF)
B23 Family Child Care Admission and Arrangement Form DHS-7776 (9-18) (PDF)
B24 Liability Insurance Notice to Parents or Guardians Family Child Care DHS-7741 (8-18) (PDF)
B25 Optional Form for Parent Statement: Infant Less Than Six Months DHS-7219 (1-24) (PDF)
B26 Rule and Statute Summary Family Child Care DHS-7747 (PDF)
B27 Allergy Information Form Family Child Care DHS-7736 (7-17) (PDF)
B28 Family Child Care Fix-It Ticket Form (4-19) (PDF)
B30 Quarterly Serious Injury Reporting Form (1-18) (PDF)
B31 Program Plan DHS-8206A (7-22) (PDF)
B32 Primary Provider of Care DHS-8281 (8-22) (PDF)
Child Foster Care – Section C
C1 Statement of Intended Use (1-15) (PDF)
C2 Child Foster Care Capacity Guidelines and Commonly Asked Questions DHS-8361 (11-22) (PDF)
C4 Capacity and Ratio Variance Request Form – Child Foster Care DHS-3755D (9-19) (PDF)
C6 Procedures for Emergency Relative Foster Care Placements Bulletin (2-16) (PDF)
C7 Referral Form - Emergency Relative Placement Child Foster Care DHS-5178 (8-16) (PDF)
C8 2960 Child Foster Care Licensing Checklists
- C8a Licensing Checklist – Family Child Foster Care (2-21) (PDF)
- C8b Corporate Child Foster Care Licensing Checklist (2-21) (PDF)
- C8c Licensing Checklist - Treatment Child Foster Care Additional Requirements (3-08) (PDF)
C10 Expiration of Disqualification Variance- Child Foster Care (11-16) (PDF)
C11 Annual Evaluation of Licensed Foster Home DHS-8338 (10-22) (PDF)
C12 Instructions to Complete Commissioner’s Designated Format for an Adoption and Foster Care Study DHS-4258 (2-19) (PDF)
C14 Individual Fact Sheet - Minnesota Adoption and Foster Care DHS-4258B (10-23) (PDF)
C16 Home Study Assessment - Minnesota Adoption and Foster Care DHS-4258D (2-17) (PDF)
C17 Home Study Assessment Update - Minnesota Adoption and Foster Care DHS-4258E (9-22) (PDF)
C19 Agreement Between Foster Parents and Licensing Agency DHS-0139 (12-20) (PDF)
C19a Summary of Child Foster Care Responsible Agency Requirements DHS-0139A (11-17) (PDF)
C21 Instructions - Corporate Home Study Assessment and Assessment Update (12-15) (PDF)
C22 Home Study Assessment for Corporate Child Foster Care (10-15) (PDF)
C23 Home Study Assessment Update for Corporate Child Foster Care (12-15) (PDF)
C24 Child Foster Care Variances to Minnesota Rules DHS-8530 (1/24)(PDF)
C25 Fact Sheet - Corporate Child Foster Care (9-15) (PDF)
C26 Respite and Substitute Care for Family Settings- Definitions and Requirements (10-16) (PDF)
C27 Licensed Child Foster Care Moving – one county to another (5-19) (PDF)
C29 Mental Health and Fetal Alcohol Spectrum Disorders Training for Child Foster Care (4-21) (PDF)
C30 Initial Two-Year License for Relative and PPAI Applicants (3-22) (PDF)
C31 Reference Letter CFC Sample (8-18) (DOCX)
C32 Discipline Policy sample (5-18) (PDF)
C33 Complaint and Grievance Policy sample for foster children (9-18) (PDF)
C34 Children in Foster Care: Babysitting Guidelines DHS-7830 (1-19) (PDF)
C35 C.A.R.S. Training – Variance Guidelines & Process for Licensors DHS-3755B (10-21) (PDF)
C36 C.A.R.S. Training – Variance Request & Approval DHS-3755C (10-21) (PDF)
C37 Children in foster care: Using relative visits and alternative child care arrangements DHS-7830A (3-19) (PDF)
C38 Non-Disqualifying Background Study Information Assessment DHS-8279 (7-22) (PDF)
C39 Relative Applicant Overview (7-22) (PDF)
C40 CFC Background Studies Reform Flow Charts (7-22) (PDF)
C41 CFC Background Studies Reform FAQ (1-23) (PDF)
Adult Foster Care/Community Residential Setting – Section D
Please note – several of the forms developed for Adult Foster Care have been removed from the site temporarily. Each form is being reviewed by Family Systems in light of the new 245D legislation. Updates will be provided to agency licensing workers via the license renewal report.
D1 AFC Exemptions under Dually Licensed AFC and 245D HCBS Programs (4-14) (PDF)
D2 Emergency Crisis Respite 5th Bed Variance
- D2a Initial License Holder Request for Crisis Capacity Variance DHS-7813 (11-18) (PDF)
- D2b Initial County Request for Crisis Capacity Variance DHS-7811 (11-18) (PDF)
- D2c General License Holder Request for Crisis Capacity Variance DHS-7812 (11-18) (PDF)
- D2d General County Request for Crisis Capacity Variance DHS-7810 (11-18) (PDF)
D4 Rule 203 Adult Foster Care Licensing Checklists
- D4a Licensing Checklist - Family and Corporate Adult Foster Care without HCBS (6-21) (PDF)
- D4b Licensing Checklist - Family Adult Foster Care with HCBS (6-21) (PDF)
D5 Program Abuse Prevention Plan sample (6-15) (PDF)
D6 Program Abuse Prevention Plan - Version 2 (1-15) (PDF)
D13 Individual Abuse Prevention Plan (IAPP) (8-18) (PDF)
D14 Individual Resident Placement Agreement (12-13) (PDF)
D15 License for Five Checklist (12-13) -This form is being revised; contact dhs.LicensingCRS@state.mn.us with questions.
D17 Adult Foster Care Program Plan (8-18) (PDF)
D19 Medical Monitoring Equipment Training and Skills Form DHS-8319 (9-22) (PDF)
D20 Alternate Overnight Supervision Technology Checklist (12-13) (PDF)
D26 Adult Foster Care Mental Health Certification
- D26a Instructions for Completing a Request for a Mental Health Certification (10-14) (PDF)
- D26b Request for Mental Health Certification (10-14) (PDF)
- D26c Attachment A: Mental Health Certification (7-15) (PDF)
- D26d Attachment B: Mental Health Certification (3-13) (PDF)
- D26e Adult Foster Care and Community Residential Services Mental Health Certification Licensing Checklist DHS-8359 (11-22) (PDF)
D27 Community Residential Setting (CRS)
D28 Ceiling Height Variance Request Form (5-17) (PDF)
D29 Vulnerable Adults Act Summary DHS-8318 (9-22) (PDF)
D30 Adult Foster Care Resident Rights (8-18) (DOCX)
D31 Adult Foster Care Reference Letter Sample (5-18) (DOCX)
D32 Grievance Procedures for Adult Foster Care (8-18) (PDF)
D33 Family Adult Foster Care Licensing – Policy Clarification DHS-8435 (8-21) (PDF)
Family Adult Day Services (FADS) – Section E
E1 Licensing Checklist – FADS (7-17) (PDF)E2 Questions and Answers - FADS (7-12) (PDF)
E3 Policy and Program Information – FADS DHS-8314 (9-22) (PDF)
E4 Individual Service Delivery Plan - FADS DHS-8315 (9-22) (PDF)
E5 Requirement Chart – FADS (12-13) (PDF)
Background Studies – Section F
F5 Family Child Foster Care Disqualification Chart (7-22) (XLS)F6 Risk of Harm Determination Worksheet (1-07) (PDF)
F11 Request for Reconsideration of Disqualification Form – for County/Private Agency’s Use (4-08) (PDF)
F22 Child Foster Care (CFC) and Adoptions Background Study Identification Form (10-12) (PDF)
F24 Variance Expiration Extension Request for Family Child Care (1-19) (PDF)
Family Systems Applications – Section H
H2 Family Child Care
H4 & H5 Child Foster Care and Adult Foster Care/Community Residential Settings
- H4a Application – Minnesota Adoption and Child Foster Care DHS-4258A (9-22) (PDF)
- H4c Application – Minnesota Corporate Child Foster Care DHS-4258H (8-17) (PDF)
- H5a Application - FAMILY Adult Foster Care; Family Adult Day Services; Alternate Overnight Supervision Technology (5-17) (PDF)
- H5b Supplement to Application – FAMILY Adult Foster Care DHS-8132 (6-21)
- H5c Application - CORPORATE AFC; Community Residential Setting; FADS; Alternate Oversight Technology (5-17) (PDF)
H7 Preliminary Information Form (PIF) - all license types (DHS-7779)
H8 3324 License Recommendation - all license types
H9 Withdrawal of License Application DHS-7941 (11-22) (PDF)
