DHS Program Resources Licensing

Community Residential Settings Licensor Library

This page lists forms and resources used by workers to license community residential settings (CRS).

Quick links to websites that licensors may use

Office of the Revisor of Statutes website
Minnesota Statute 245D Home and Community Based Services licensing
Licensing Information Lookup website
Electronic Licensing Monitoring System (ELMS) website
NETStudy 2.0 website

Quick links to sections on this page

NOTE: You can use the blue arrow in the lower right corner to quickly jump back to the top of the page.

3324/Closing/Extension
Application
Checklists
Complaint/Correction Order
Fire Marshal forms and information
General forms and resources
Mental health certification
Policies/Plans/Required forms
Variance forms

3324/Closing/Extension

3324 Closing Codes (12-13) (PDF)
3324 EZ License Renewal Recommendation Form DHS-3324 (2-19) (PDF)
3324 License Recommendation - CFC AFC CRS FADS (8-17) (PDF)
License Extension Request or Closure Pending Investigation Form (11-21)

Application

Corporate Application - AFC; Community Residential Setting; FADS; Alternate Overnight Supervision Technology (5-17) (PDF)

Checklists

Home Safety Checklist – Adult Foster Care or Community Residential Setting (9-21) (PDF)
Licensing Checklist - Community Residential Setting (8-15) (PDF)
Alternate Overnight Supervision Technology Checklist (12-13) (PDF)
License for Five Checklist -This form is being revised; contact dhs.LicensingCRS@state.mn.us with questions.

Complaint/Correction Order

Complaint Log Sample (11-12) (PDF)
Correction Order Form (3-19) (PDF)
Licensing Intake Complaint Form (10-13) (PDF)

Fire Marshal forms and information

DHS and Fire Marshal Interagency Agreement (8-16) (PDF)
Owners Permission for Fire Marshal Inspection (10-19) (PDF)
Request for Fire Inspection or Reinspection DHS-7786 (10-18) (PDF)
State Fire Marshal – Child Care/Foster Care Inspections webpage

General forms and resources

Commissioner Access Letter (2-18) (PDF)
Data Privacy Guidelines Regarding Family Systems Programs (4-14) (PDF)
Emergency Escape Plan for Foster Care (4-17) (PDF)
Licensing Tracking Log (3-08) (PDF)
Medical Monitoring Equipment Training and Skills Form (4-07) (PDF)

Mental health certification

Attachment A- Mental Health Certification (7-15) (PDF)
Attachment B- Mental Health Certification (3-13) (PDF)
Instructions for Completing a Request for Mental Health Certification (11-14) (PDF)
Mental Health Certification Licensing Checklist (9-12) (PDF)
Request for Mental Health Certification (11-14) (PDF)

Policies/Plans/Required forms

Program Abuse Prevention Plan sample (6-15) (PDF)
Vulnerable Adult Act Summary (3-21) (PDF)

Variances

Initial License Holder Request for Crisis Capacity Variance DHS-7813 (11-18) (PDF)
Initial County Request for Crisis Capacity Variance DHS-7811 (11-18) (PDF)
General License Holder Request for Crisis Capacity Variance DHS-7812 (11-18) (PDF)
General County Request for Crisis Capacity Variance DHS-7810 (11-18) (PDF)
Variance Request Form - Family Systems (7-21) (PDF)
Variance Request form- DHS 3141 (7-18) (PDF)