Adult foster care current license holders
This page offers quick and easy access to important forms and frequently accessed information for all license types.
Relicensing forms
- Corporate Relicensing Letter (PDF)
- AFC Capacity Change Request (PDF)
- Census and Home Information Form (PDF)
- Corporate Adult Foster Care Family Systems License Application (PDF)
- Corporate Licensing Application (PDF)
- DHS Workers Compensation Certification (PDF)
- DHS Home Safety Checklist (PDF)
- Equipment Maintenance Form (PDF)
- Pet Authorization Form (PDF)
- Relicensing Letter for Family AFC with HCBS/245D (PDF)
- Adult Foster Care Supplement Form (DOC)
- Capacity Change Guidelines and Request Form (PDF)
- Census and Home Information Form (PDF)
- DHS Home Safety Checklist (PDF)
- DHS Workers Compensation Certification (PDF)
- Equipment Maintenance Form (PDF)
- Family AFC with HCBS Application (PDF)
- Licensing Checklist for Family AFC with HCBS/245D (PDF)
- Pet Authorization Form (PDF)
- Vulnerable Adults Mandated Reporting (VAMR) Training
- Relicensing Letter for Family AFC without HCBS (PDF)
- Adult Foster Care Supplement Form (DOC)
- Capacity Change Guidelines and Request Form (PDF)
- Census and Home Information Form (PDF)
- DHS Home Safety Checklist (PDF)
- DHS Notice of Privacy Practice Signature Document (PDF)
- DHS Workers Compensation Certification (PDF)
- Equipment Maintenance Form (PDF)
- Family AFC Application (PDF)
- Licensing Checklist for Family AFC without HCBS/245D (PDF)
- Medical Monitoring Equipment Training and Skills Form (PDF)
- Pet Authorization Form (PDF)
- Vulnerable Adults Act Summary (PDF)
- Vulnerable Adults Mandated Reporting (VAMR) Training
- Capacity Change Guidelines and Request Form (PDF)
- Census and Home Information Form (PDF)
- DHS Workers Compensation Certification (PDF)
- Fire extinguisher serviced
- Pet Authorization Form (PDF)
- Program Abuse Prevention Plan Template (PDF)
- Social History Form - Adult (PDF) - complete if you have a new household member and/or minor turning 18
- Social History Form - Child (PDF) - if a child in the home is turning 13 this year, they must complete a Social History Form - Child and complete a background study. Contact your RLS for more information.
- Vulnerable Adults Act Summary (PDF)
Additional forms
Serious injury or death
If you witness or suspect that a resident is being maltreated, abused, or neglected, you must call the state reporting line at 844-880-1574. Also, complete an incident report form.
If a resident is developmentally delayed, mentally ill or elderly, you must report any serious injury or death to the Department of Human Services-Office of the Ombudsman (1-800-657-3591), as well as the case manager, guardian, and your regional licensing specialist.
Access forms and additional information on the OMHDD website >
Incident
In compliance with Minnesota statute 9555.6175, the following items require reporting to your regional licensing specialist within the specified timeframes:
- resident death or serious injury, including any that requires medical treatment - immediately with Required Reporting Form (PDF)
- Incident report form (PDF)
- diagnosis of a resident, caregiver or household member with a communicable disease - immediately
- fire, storm, or other damage to the home - within 24 hours with Natural Disasters form (PDF)
- building repair or remodeling that requires a building permit - within 24 hours
- change in health status of a caregiver that could affect ability to care for a resident - within 24 hours
- change in the regular membership of the household or caregiver's employment status - within five calendar days
- transfer or voluntary discharge of a resident - within seven calendar days
- involuntary discharge of a resident who does not have an individual service plan - at least 30 days before
For your convenience, sample documents or forms have been provided.
- Document guide (DOC)
- Host home guidelines (PDF)
- Adult foster care background study roster reporting (PDF)
- Adult foster home program plan (PDF)
- Complaint and grievance procedures (PDF) - must also be posted
- Drug and alcohol policy (PDF)
- Emergency fire and escape plan (PDF) - must also be posted
- Emergency fire drill log (DOC)
- Emergency plan and procedures sample template (DOC)
- Program abuse prevention plan - PAPP (PDF) - must also be posted
- Program abuse prevention plan - PAPP sample (PDF)
- Service termination policy (DOC)
- Social history form - Child (PDF) - Complete for all new minor household members and when household members turn 13 years old.
- Social history form - Adult (PDF)
- Substitute caregiver plan (PDF)
Please maintain a copy of the following in your files. Your RLS may ask to review these documents.
- Annual housing support vendor profile form
- Annual well water testing (coliform and nitrates)
- Background schedule clearance letter for AFC license
- Emergency equipment testing & replacement (PDF) - smoke and carbon monoxide alarms
- Fire extinguisher reservicing options (PDF)
- Resident File Sample (DOC)
- Resident Information Sheet Sample (PDF)
- Cash Resources (PDF)
- Individual Abuse Prevention Plan (PDF)
- Individual Resident Placement Agreement (PDF)
- Medication Permissions (PDF)
- Mobility access assessment (PDF)
- Notice of Privacy Practices (PDF)
- Prescription Drug Disposal Collection Bins (PDF)
- Resident Record Admission Checklist (PDF)
- Resident Rights (PDF)
- Signed notification of a communicable/contagious disease, if applicable
- Vulnerable Adult Act Summary (PDF)
- Resident progress notes
Please maintain a copy of the following in your files. Your RLS may ask to review these documents.
- Guardian or other court paperwork
- Resident progress notes
- Release of information ROI's
Training information
In addition to orientation training, each caregiver must complete training designed to meet the needs of residents as outlined below.
- caregivers with zero to five years of licensure or experience as an adult foster home caregiver must complete 12 hours training a year
- caregivers with six or more years of licensure or experience as an adult foster home caregiver must complete six hours training a year
- caregivers who provide services according to a contract between the operator and the department or service must comply with any additional training requirements stated in the terms of the contract
The operator of the home must ensure that a record of completed training is maintained.
Online required training for vulnerable adult maltreatment reporting is available through DHS.
The following individuals are exempt from the training hours requirements:
- caregivers providing no more than 30 cumulative days of foster care in a 12-month period
- caregivers providing foster care no more than eight hours a week
DHS license lookup
Verify your license by name, county, or license number.
Questions
Contact licensing@sourcewell-mn.gov or call 218-895-4120.
Please include your county of residence in all communications.