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: |      |

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| |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 |

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|D. |Education: |

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| |School |City/state |Degree or number of years |Year |

| | |(country if outside the USA) | | |

| | | | | |

| |      |      |      |      |

| |      |      |      |      |

| |      |      |      |      |

|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: |      |

| |

|3 ─ Resident information |

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|A. |      | | |      |

| |Resident’s name | | | |Date of birth |

| |

|B. |      | |      |

| |Case manager (if applicable) | |Case manager contact phone number |

| |

|C. |      |

| |Resident’s diagnosis |

| |

|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 |

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|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. |

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|Signature of applicant | |Date |

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