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)
- Certificate of Compliance Minnesota Workers' Compensation Form (PDF)
- Corporate Adult Foster Care Family Systems License Application (PDF)
- DHS Home Safety Checklist (PDF)
- Equipment Maintenance Form (PDF)
- Pet Authorization Form (PDF)
- Relicensing Letter for Family AFC with HCBS/245D (PDF)
- Supplemental Application (PDF)
- Capacity Change Guidelines and Request Form (PDF)
- Census and Home Information Sheet (PDF)
- Certificate of Compliance Minnesota Workers' Compensation Form (PDF)
- DHS Home Safety Checklist (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)
- Supplemental Application (PDF)
- Capacity Change Guidelines and Request Form (PDF)
- Census and Home Information Sheet (PDF)
- Certificate of Compliance Minnesota Workers' Compensation Form (PDF)
- DHS Home Safety Checklist (PDF)
- DHS Notice of Privacy Practice Signature Document (PDF)
- Equipment Maintenance Form (PDF)
- Family AFC Application (PDF)
- Licensing Checklist for Family AFC without HCBS/245D (PDF)
- Medical Monitoring Equipment 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 Sheet (PDF)
- Certificate of Compliance Minnesota Workers' Compensation Form (PDF)
- Equipment Maintenance Form (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)
- AFC Checklist for Provider Requirements (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 (PDF)
- Resident Placement and Demographic Information (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 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
- caregiver training log template
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.