ࡱ> ?A:;<=>o bjbjZZ 2n8zf8zfC87DQ&"("""#)$,PPPPPPP$TV8PE/##E/E/P""Q:::E/F""P:E/P::K|1M"R '/RYLPQ0QkLY/VY$1MY1MX."z.:..X.X.X.PP35zX.X.X.QE/E/E/E/YX.X.X.X.X.X.X.X.X. : Limited Adult Foster Home Application Type of limited Adult Foster Home (AFH) license requested:  FORMCHECKBOX  New  FORMCHECKBOX  Renewal1 % General informationA.Applicant s name: FORMTEXT      B.Applicant s date of birth: FORMTEXT      C.Phone:  FORMTEXT       FORMTEXT       FORMCHECKBOX  check if noneApplicant home phoneApplicant cell phoneD.AFH address: FORMTEXT       FORMTEXT       Street City/state/ZIP codeE.Mailing address (if different):  FORMTEXT       F.Applicant s email address:  FORMTEXT       FORMCHECKBOX  check if none 2 % Applicant informationA.Are you now, or have you ever been licensed or certified as a licensee, resident manager or shift caregiver in a foster home? FORMCHECKBOX  Yes FORMCHECKBOX  NoIf yes, what county? (If outside Oregon, indicate where.)  FORMTEXT      Identify the agency or agencies that issued the foster home license(s) or certificate(s): FORMCHECKBOX  DD (Developmental Disabilities)  FORMCHECKBOX  APD (Aged and Physically Disabled) % (formerly Seniors and People with Disabilities) FORMCHECKBOX  Multnomah County Adult Care Home Program FORMCHECKBOX  CAF (Children, Adults and Families) FORMCHECKBOX  Veterans Administration FORMCHECKBOX  Mental Health FORMCHECKBOX  Other state: FORMTEXT      B.Emergency contact(s): Provide information for at least one contact.NamePhone numberRelationship to applicant FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      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?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, by whom? FORMTEXT      Date: FORMTEXT      Have you ever had a substantiated allegation of abuse or neglect? FORMCHECKBOX  Yes FORMCHECKBOX  No If yes, by whom? FORMTEXT      Date: FORMTEXT      Have you ever been placed on the Office of Inspector General s (OIG) Exclusion List or the General Services Administrations (GSA) Exclusion List? (Individuals on the OIG pr the GSA Exclusion List are prohibited from participating in any Federally funded health care program.)   FORMCHECKBOX  Yes FORMCHECKBOX  NoD.Education:SchoolCity/state (country if outside the USA)Degree or number of yearsYear FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       E.Special qualifications: Attach a current copy of any license or certificate. FORMCHECKBOX Registered nurseLicense number: FORMTEXT       FORMCHECKBOX Licensed practical nurseLicense number: FORMTEXT       FORMCHECKBOX Certified medical assistantCertificate number: FORMTEXT       FORMCHECKBOX Certified nursing assistantCertificate number: FORMTEXT       FORMCHECKBOX Other:  FORMTEXT      Certificate number: FORMTEXT      3 % Resident informationA. FORMTEXT       FORMTEXT      Resident s nameDate of birthB. FORMTEXT       FORMTEXT      Case manager (if applicable)Case manager contact phone numberC. 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"""$"&"("*">"@"B"D"F"H"J"L"N"P"R"T"h"r"ɻɻufhDShOJQJ^JaJheZrOJQJ^JaJ!jJCh0OJQJU^JjhzNOJQJU^J!jBh0OJQJU^Jh0OJQJ^Jjh0OJQJU^JhDShOJQJ^JhDSheasOJQJ^JhDSheas5OJQJ^JhDSh5OJQJ^J#!!!$"&"("P" $Ifgd$IfQkdPB$$IfTl4++ t+ 44 laf4p yts+#TP"R"T"t"v"x"@:1:1 $Ifgdeas$IfkdC$$IfTlr}r+$ t+ 22s22s44 lap2yts+#Tr"t"v"x"z""""""""""""""""""""""""""""""""#䷷o`hDSh#r%OJQJ^JaJ!jFh0OJQJU^JjhzNOJQJU^J!jHFh0OJQJU^Jh0OJQJ^Jjh0OJQJU^JhDSh#r%OJQJ^JhDShOJQJ^JaJ hDSheasCJOJQJ^JaJhDSheasOJQJ^JhDSheasOJQJ^JaJ$x"z"" $Ifgd#r%$If"""$IfkdD$$IfTlֈ}r+  $ t+ 22s22s22s44 lap<yts+#T"""""" $Ifgd$IfQkdE$$IfTl4++ t+ 44 laf4p yts+#T"""2#4#x#XRIRI $Ifgd#r%$IfkdG$$IfTl\+ t+ 22s22s44 lap(yts+#T##0#2#4#\#v#x#z#|#~####################$,ĵħ~~~~~ĵqcacUhDShq) 5OJQJ^JhDShq) OJQJ^JjhzNOJQJU^J!jIh0OJQJU^Jh0OJQJ^Jjh0OJQJU^JhDSh#r%OJQJ^JaJhDSh#r%OJQJ^JhDSh#r%6OJQJ^JaJhDShq) 6OJQJ^JaJhDShq) OJQJ^JaJ x#z#|#XR$IfkdH$$IfTl\+ t+ 22s22s44 lap(yts+#T|#~#####3mkd^J$$IfTl0+) t+ 22s44 lapyts+#T $Ifgd$IfNkd`I$$IfTl++ t+ 44 lap yts+#T######~/~NkdK$$IfTl++ t+ 44 lap yts+#T$IfrkdJ$$IfTl0+) t+ 2s22s44 lapyts+#T $Ifgd#r% outside of the home?  FORMCHECKBOX  Yes FORMCHECKBOX  No If yes, number of hours per week you will work: FORMTEXT      E.Name of employer: FORMTEXT      F.Explain how the resident will be provided care when you are not home: FORMTEXT      4 % Occupants and caregiversIdentify 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).NameRelationshipOccupants date of birthCaregiver FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No5 % Additional application requirements check listAttach 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. FORMCHECKBOX 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.  FORMCHECKBOX  N/A FORMCHECKBOX 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). FORMCHECKBOX 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. 6 % Certification and signatureI 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; andAn 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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LDCheck13kNo, have not been a licensed/certified as a licensee, resident manger, or shift cregiver in a foster home. $$Ifl!vh#v#vn#v#v9:V l t#+,55n55922s222s2p(ytDSTDText9:If yes, what county? (If outside Oregon, indicate where.) $$Ifl!vh#v#v(#vf :V l t#+55(5f / 22s22spytDSTW$$Ifl!vh#v+:V l t#+5+p ytDST}$$Ifl!vh#v#v):V l t#+55)22spytDST:DCheck88bDevelopmental Disabilities (DD) is the agency that issued the foster home license or certificate. }$$Ifl!vh#v#v):V l t#+55)22spytDST@DCheck89eAPD (Aged and Physically Disabled) is the agency that issued the foster home license or certificate.}$$Ifl!vh#v#v):V l t#+55)22spytDSTJDCheck90jMultnomah county adult care home program is the agency that issued the foster home license or certificate.$$Ifl!vh#v#v#v :V l t#+555 22spytDSTBDCheck84fCAF (Childeren, Adults and Families) is the agency that issued the foster home license or certificate.$$Ifl!vh#v#v#v :V l t#+,555 22spytDST(DCheck75YVeterans administration is the agency that issued the foster home license or certificate.DCheck76OMental health is the agency that issued the foster home license or certificate.$$Ifl!vh#v#v#v#vZ :V l t#+,5555Z 22sp(ytDSTDCheck77=Another state issued the foster home license or certificate. DText148@List the other state(s) that issued the license or certificate. $$Ifl!vh#v#v#v!:V l t#+,555!/ 22spytDST]$$Ifl!vh#v+:V l4 t#+5+f4p ytDST}$$Ifl!vh#v#v):V l t#+55)22spytDST}$$Ifl!vh#v#v2):V l t#+552)/ pytDST$$Ifl!vh#v#v#v#vf :V l  t(#+5555f / / p(ytDSTDText10Emergency contact nameDText11Emergency contact phone numberDText12Relationship to applicant$$Ifl!vh#v#v#v#vf :V l t#+5555f / / 22sp(ytDSTDText13Emergency contact nameDText14Emergency contact phone numberDText15Relationship to applicant$$Ifl!vh#v#v#v#vf :V l t#+5555f /  / /  22sp(ytDST$$Ifl!vh#v#v2):V l4b t#+552)/  f4pytDST$$Ifl!vh#v#v):V l t#+55)2222spytDST$$Ifl!vh#v#v2):V l4 t#++552)22spytDST$$Ifl!vh#v#v2):V l4 t#++552)22spytDSTDCheck22Have 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? Yes, I have had my license/certificate for a foster home or long term care facility denied, suspended, revoked or voluntarily surrendered.DCheck23No, my license/certificate for a foster home or long term care facility hasn't been denied, suspended, revoked or voluntarily surrendered.DText16If yes, by whom?6DText17`Date of when the license/certificate was denied, suspended, revoked or voluntarily surrendered. 5$$Ifl!vh#v#v#v #v #v{#v:V l t#+,555 5 5{5/ / 222s222s22sp<ytDSTu$$Ifl!vh#v#v2):V l4 t#+552)f4pytDSTk$$Ifl!vh#v#v2):V l t#+552)pytDSTfD@Yes, I have had a substantiated allegation of abuse or neglect. ?Yes, I have had a substantiated allegation of abuse or neglect.rDCNo, I have not had a substantiated allegation of abuse or neglect. BNo, I have not had a substantiated allegation of abuse or neglect.DText18If yes, by whom?2DText196Date of substantiated allegation of abuse or neglect. (Date of allegation of abuse or neglect. 5$$Ifl!vh#v#v#v #v #v#v:V l t#+,555 5 55/ / 222s222s22sp<ytDST]$$Ifl!vh#v+:V l4 t#+5+f4p ytDST$$Ifl!vh#v#v2):V l t#+552)22spytDSTjDCheck62Have you ever been placed on the Office of Inspector General s (OIG) Exclusion List or the General Services Administration s (GSA) Exclusion List?hYes, I am on the Office of Inspector General's or the General Services Administration's Exclusion list. LDCheck63kNo, I am not on the Office of Inspector General's or the General Services Administration's Exclusion list. $$Ifl!vh#v#v#v#v{:V l t#+,5555{222s2p(ytDSTu$$Ifl!vh#v#v2):V l4 t#+552)f4pytDST}$$Ifl!vh#v#v2):V l t#+552)22spytDST$$Ifl!vh#v#v2):V l4 t#+552)/ f4pytDST:$$Ifl!vh#v#v #v #v~ #vB:V l4  t2#+++++55 5 5~ 5B/ / 22sp2ytDST($$Ifl!vh#v#v #v #v~ #vB:V l4  t2#+++++55 5 5~ 5B/ / p2ytDSTDText20Education: Name of schoolDText21)City/state (country if outside the USA) DText22Degree or number of years~DText23Year$$Ifl!vh#v#v #v #v~ #vB:V l t#+55 5 5~ 5B/ / 22sp2ytDSTDText24Education: Name of schoolDText25'City/state (country if outside the USA)DText26Degree or number of years~DText27Year$$Ifl!vh#v#v #v #v~ #vB:V l t#+55 5 5~ 5B/ / 22sp2ytDSTDText28Education: Name of schoolDText29'City/state (country if outside the USA)DText30Degree or number of years~DText31Year$$Ifl!vh#v#v #v #v~ #vB:V l t#+55 5 5~ 5B/ / 22sp2ytDST$$Ife!vh#v#v):V l t+ 55)22sapyts+#T>DCheck64dSpecial qualifications as a registered nurse (attach a current copy of any license or certificate.) DText132License number$$Ife!vh#v#vG#v#v #v :V l t+ ,55G55 5 / 2222s22sap2yts+#TNDCheck65lSpecial qualifications as a licensed practical nurse (attach a current copy of any license or certificate.) 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