Adult Foster Home .us - Certificate in american sign language

|[pic] |Adult Foster Home License Supplemental Application |

|Safety, Oversight and Quality Unit | |

|Type of Adult Foster Home (AFH) application: |

|(Type or use ink to complete. Check one box per application.) |

| Co-applicant Administrator Resident manager Shift caregiver |

|Part 1 ─ To be completed by applicant |

|1 ― General information |

|A. |Applicant name: | |Birth date: | |

|B. |Phone: | | | |

| | |Applicant’s home phone | |Applicant’s cell number |

|C. |Adult Foster Home (AFH) street address: | |

|. |City: | |State: | |ZIP code: | |

| | |

|D. |Mailing address (if different): | |

| |City: | |State: | |ZIP code: | |

|E. |Applicant’s email address: | | check if none |

| | Required for co-applicant |

|F. |Classification: Select the license classification you are requesting. |

| | Class 1 Class 2 Class 3 |

| |Note: The classification of your AFH license will be determined based on OAR 411-049-0105(9) for specific classification criteria. |

|2 ― Applicant information |

|A. |Is the house where you are applying to operate an AFH your current primary residence where you live?” Yes No |

| |If yes, should this application be approved for you to operate an AFH will this home continue to be your primary residence. Yes No |

| |If no, please provide your primary address: | |

|B. |Are you now, or have you ever been licensed or certified as a provider, administrator, resident manager or caregiver in an AFH? Yes No |

| |If yes, what county? (If outside of Oregon, indicate where.) | |

| |Identify the agency or agencies that issued the AFH license(s) or |

| |other certificate(s): |

| | |DD (Developmental Disabilities) | |

| | |APD (Aging and People with Disabilities, formerly Seniors and |

| | |People with Disabilities) |

| | |DHS (Child Welfare, Self-Sufficiency, Child Care) |

| | |County ordinance (Multnomah/Clackamas) |

| | |Mental health |

| | |Veterans administration | Other state: | |

|Applicant information (continued) |

|C. |Emergency contact(s): Provide information for at least one contact. |

| |Name |Phone number |Relationship to applicant |

| | | | |

| | | | |

|D. |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 have you voluntarily surrendered|

| |a license or certificate while under sanction? Yes No |

| | |

| |If yes, by whom? | |Date: | |

| |Have you ever had a substantiated finding 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? Yes No |

| |(Individuals on the OIG or the GSA exclusion lists are prohibited from participating in any federally funded health care program.) |

| | |

| | |

|E. |Education: |

| |School |City |Degree or number |Year |

| | |(Add country if |of years | |

| | |outside the USA) | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|F. |Special qualifications: |

| | |Registered nurse |License number: | |

| | |Licensed practical nurse |License number: | |

| | |Certified medical assistant |Certificate number: | |

| | |Certified nursing assistant |Certificate number: | |

| | |American sign language |

| | |Fluent in language(s) other than English | |

| |Special qualifications (continued) | |

| |List languages: | |

| | Other: | |

|G. |Training (attach verification): |

| | |Fire and Life Safety (within first year) |

| | |Basic first aid (required within the first year – if you are currently certified in CPR attach a copy of both sides of your certification card) first |

| | |aid certification is required to be maintained after your first year of licensure |

| | |Cardiopulmonary Resuscitation (CPR) (attach a copy of both sides of your certification card. CPR certification is required to be maintained after your |

| | |first year of licensure) |

Applicant information (continued)

H. Medical professional references: If you are requesting to operate or work in a

Class 3 AFH, identify two medical professionals on the following page who have

direct knowledge of your ability and past experience as a caregiver.

(Note: Medical professional means licensed health care professionals such as a medical doctor, osteopathic physician, nurse practitioner, registered nurse, physical therapist, occupational therapist or respiratory therapist.)

| |Do not include the name of your personal health care provider unless he or she has direct knowledge of your experience as a caregiver. |

| |Name and title of medical professional: | |

| |Phone number: | | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Name and title of medical professional: | |

| |Phone number: | | | | | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

|I. |List all occupants in your home: Include all persons who live in your adult foster home. Examples: children, spouses, residents, live-in caregivers, room and |

| |board occupant. (Attach additional pages if necessary.) |

| |AFH occupant names: |Relationship to applicant: |Date of birth: |

| | | | |

| | | | |

| | | | |

| | | | |

|J. |Work history: List your caregiving experience for the last five years starting with your most current job (attach a separate sheet of paper if needed). |

| | |

| |Contact person: | |

| |Name of business: | |Phone: | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Your job title: | |

| |Start date (month/year): | |End date (month/year): | |

| |Hours worked per week: | | |

| |Did you provide care to persons who were dependent in three or more ADLs? |

| |Yes No |

| |Describe your job duties: |

| | |

| |Contact person: | |

| |Name of business: | |Phone: | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Your job title: | |

| |Start date (month/year): | |End date (month/year): | |

| |Hours worked per week: | | |

| |Did you provide care to persons who were dependent in 3 or more ADLs? |

| |Yes No |

| |Describe your job duties: |

| |Contact person: | |

| |Name of business: | |Phone: | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Your job title: | |

| |Start date (month/year): | |End date (month/year): | |

| |Hours worked per week: | | |

| |Work history (continued) |

| |Did you provide care to persons who were dependent in 3 or more ADLs? |

| |Yes No |

| |Describe your job duties: |

| |Contact person: | |

| |Name of business: | |Phone: | |

| |Mailing address(Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Your job title: | |

| |Start date (month/year): | |End date (month/year): | |

| |Hours worked per week: | | |

| |Did you provide care to persons who were dependent in 3 or more ADLs? |

| |Yes No |

| |Describe your job duties: |

| |Contact person: | |

| |Name of business: | |Phone: | |

| |Mailing address(Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Your job title: | |

| |Start date (month/year): | |End date (month/year): | |

| |Hours worked per week: | | |

| |Did you provide care to persons who were dependent in 3 or more ADLs? |

| |Yes No |

| |Describe your job duties: |

|K. |General references: Provide three references that are not related to you. Current or potential AFH licensees and coworkers of the applicant are not eligible |

| |to be a general reference. |

| | |

| |Name: | |Phone number: | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Name: | |Phone number: | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

| |Name: | |Phone number: | |

| |Mailing address (Street/P.O. Box): | |

| |City: | |State: | |ZIP code: | |

|3 ― Additional application requirements checklist |

| |Include copies of the following documents with your completed application. Check the corresponding boxes to indicate completion or check the box marked N/A if|

| |it does not apply to you. |

| | |

| | |

| | |Physician or Nurse Practitioner’s Statement: Submit the completed, signed and dated original of the Department’s current Health History and |

| | |Physician/Nurse Practitioners Statement (APD 0903). |

| | | |

| | | |

| | |Background check verification: Enclose verification of an approved background check for all persons 16 years of age and older who are occupants on the |

| | |AFH premises, the licensed provider, resident manager, shift caregiver substitute caregiver, trainee or other employees and according to OAR |

| | |411-049-0120(1) AND 411-049-0102(88). This verification must be less than one (1) year old. |

| | | |

| | | |

| | | |

| | |Training: Attach proof of required training and any special credentials, as identified on page 2 and 3 (G) and (H). |

| | | |

| | |Orientation: Attach proof of attending an adult foster home orientation. The orientation must have been provided by the local licensing office. |

| | |$10.00 fee: If applying for resident manager, co-applicant, administrator or shift caregiver during the period the AFH license covers (fee is not |

| | |required if submitted with initial or renewal application). N/A |

|4 ― 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: |

|failure to provide accurate information may result in the denial of my application; |

|my application is not complete until all required items have been submitted; and |

|an incomplete application will become void in sixty (60) days from the date the application and fee are received by the Division. |

| |

|I authorize the Department to verify the information provided on this application. |

| |

| | | |

|Applicant’s printed name | |Date |

| | | |

| | | |

|Signature of applicant | |Date |

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