Limited Adult Foster Home Application
|[pic] |Limited Adult Foster Home Application |
|Type of limited Adult Foster Home (AFH) license requested: New Renewal |
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|1 ─ General information |
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|A. |Applicant’s name: | |
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|B. |Applicant’s date of birth: | |
|C. |Phone: | | | | check if none |
| | |Applicant home phone | |Applicant cell phone | |
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|D. |AFH address: | | | |
| | Street | City/state/ZIP code |
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|E. |Mailing address (if different): | |
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| |Applicant’s email address: | | check if none |
|F. | | | |
|2 ─ Applicant information |
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|A. |Are you now, or have you ever been licensed or certified as a licensee, |
| |resident manager or shift caregiver in a foster home? | Yes | No |
| |If yes, what county? (If outside Oregon, indicate where.) | |
| |
| |Identify the agency or agencies that issued the foster home license(s) |
| |or certificate(s): |
| | DD (Developmental Disabilities) |
| | APD (Aged and Physically Disabled) ─ (formerly Seniors and People with Disabilities) |
| | Multnomah County Adult Care Home Program | |
| | CAF (Children, Adults and Families) | |
| | Veterans Administration | Mental Health | |
| | Other state: | |
| |
|B. |Emergency contact(s): Provide information for at least one contact. |
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| |Name |Phone number |Relationship to applicant |
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|C. |Applicant history: |
| |Have you ever had a license or certificate for a foster home or other long-term |
| |care facility denied, suspended, or revoked or voluntarily surrendered while |
| |under sanction? |
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| | |
| | Yes | No If yes, by whom? | |Date: | |
| | |
| |Have you ever had a substantiated allegation of abuse or neglect? |
| | Yes | No If yes, by whom? | |Date: | |
| |
| |Have you ever been placed on the Office of Inspector General’s (OIG) Exclusion List or the General Services Administration’s (GSA) Exclusion List? |
| |(Individuals on the OIG pr the GSA Exclusion List are prohibited from participating in any |
| |Federally funded health care program.) | Yes | No |
| | |
|D. |Education: |
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| |School |City/state |Degree or number of years |Year |
| | |(country if outside the USA) | | |
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|E. |Special qualifications: Attach a current copy of any license or certificate. |
| | |Registered nurse |License number: | |
| | |Licensed practical nurse |License number: | |
| | |Certified medical assistant |Certificate number: | |
| | |Certified nursing assistant |Certificate number: | |
| | |Other: | |Certificate number: | |
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|3 ─ Resident information |
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|A. | | | | |
| |Resident’s name | | | |Date of birth |
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|B. | | | |
| |Case manager (if applicable) | |Case manager contact phone number |
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|C. | |
| |Resident’s diagnosis |
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|D. |Will you work outside of the home? | Yes | No |
| |If yes, number of hours per week you will work: | | |
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|E. |Name of employer: | |
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|F. |Explain how the resident will be provided care when you are not home: |
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|4 ─ Occupants and caregivers |
|Identify all individuals living in or on the AFH premises. A background check will be required for all subject individuals (per OAR 411-049-0120(1) and OAR |
|411-049-0102 (88)) who are 16 years of age or more. |
|Note: All caregivers must be at least 18 years of age (OAR 411-049-0125(9). |
| |
|Name |Relationship |Occupants date of birth |Caregiver |
| | | | Yes | No |
| | | | Yes | No |
| | | | Yes | No |
| | | | Yes | No |
| | | | Yes | No |
| | | | Yes | No |
| | |
|5 ─ Additional application requirements check list |
|Attach or enclose copies of the following documents to your completed application. Check the corresponding boxes to indicate completion or check the box marked NA if |
|it does not apply to you. |
| | |
| | |Physician or Nurse Practitioner’s Statement: Submission from a physician, nurse practitioner or physician assistant of the completed, signed and dated |
| | |original of the Department’s current Health History and Physician/Nurse Practitioner’s Statement (APD 0903). This is required every 3rd year. N/A |
| | | |
| | | |
| | |Background Check Request: Enclose completed Background Check Request forms (MSC 0301QED), or documentation of the initiation of or copy of an approved |
| | |background check required for all subject individuals including: any persons 16 years of age and older who are occupants in or on the AFH premises, the |
| | |provider applicant, any substitute caregivers, trainees or other employees, according to OAR 411-049-0120 (1) and OAR 411-049-0102 (88). |
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| | |Caregiver Preparatory Training Workbook and any additional training: Enclose your completed workbook and documentation that you have completed any |
| | |additional training deemed necessary by the Department of Human Services. |
| | | |
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|6 ─ Certification and signature |
|I declare under penalties of perjury this information is true, correct and complete to the best of my knowledge. I understand that failure to provide accurate |
|information may result in the denial of my application and that my application: |
|Is not complete until all required items have been submitted; and |
|An incomplete application will become void sixty (60) days from the date the application and fee are received by the local licensing authority. |
| | | |
|Signature of applicant | |Date |
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