Unlicensed File Checklist



Unlicensed File ChecklistPROVIDER(S) FORMTEXT ?????FAMLINK PROVIDER NUMBER FORMTEXT ?????LICENSOR FORMTEXT ?????Required of ApplicantApplicant #1Applicant#2For Providers Taking Placement of a Child Under the Age of Two YearsApplicant#1Applicant#2Signed Application received (DCYF 10-354) FORMTEXT ????? FORMTEXT ?????Tdap; dates for all household members age seven (7) years and above FORMCHECKBOX N/A FORMTEXT ????? FORMTEXT ?????Background Authorization for 16 years and up(DSHS 09-653) FORMTEXT ????? FORMTEXT ?????DTaP: dates for all household members ages 0-6 years FORMCHECKBOX N/A FORMTEXT ????? FORMTEXT ?????Background Check Summary(DCYF 09-131) FORMTEXT ????? FORMTEXT ?????For Providers Taking Placement of a Child Birth to One Year FamLink Check on all household members regardless of age FORMTEXT ????? FORMTEXT ?????Safe Sleep Assessment FORMTEXT ????? FORMTEXT ?????CA/N Check other states if applicable Applicant Number 1Applicant Number 2 FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/APURPLE Crying Video and Education FORMTEXT ????? FORMTEXT ?????Personal Information FORMTEXT ????? FORMTEXT ?????COMMENTS FORMTEXT ?????Valid Driver’s License expires FORMTEXT ????? FORMTEXT ?????Vehicle Insurance expires FORMTEXT ????? FORMTEXT ?????LEP Form (DCYF 15-245) FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AEmergency Evacuation Plan(DCYF 16-204) FORMTEXT ????? FORMTEXT ?????References (DCYF 15-286) FORMCHECKBOX 1 FORMCHECKBOX 2 FORMCHECKBOX 3 Adult children contacted; if not, provider notes detail diligent effort: FORMCHECKBOX FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AMedical Report Form (DCYF 13-001) FORMTEXT ????? FORMTEXT ?????Financial Worksheet (DCYF 14-452) FORMTEXT ????? FORMTEXT ?????Verification of Indian Status, if applicable (DSHS 15-128) FORMTEXT ????? FORMTEXT ?????Unlicensed Household Inspection (DSHS 10-453) FORMTEXT ????? FORMTEXT ?????Marriage and/ or Divorce Decree: FORMCHECKBOX Date received from applicant OR FORMCHECKBOX Date verified on DOH website with certificate number FORMTEXT ????? FORMTEXT ?????COMPLETED BY: FORMTEXT ?????DATE FORMTEXT ????? ................
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