Record Keeping Forms

Business Records Book:

• Document

  Business Records Book Cover Sheet (12.87 KB)
• Document

  Business Records Table of Contents (116.99 KB)
• Document

  Caregiver Employment Notification updated 8.1.2017 (127.93 KB)
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  Caregiver Qualifications and Training Log (optional) (34.34 KB)
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  Caregiver Checklist (102.26 KB)
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  Caregiver Workbook Certificate (72.97 KB)
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  Fax Cover Sheet (optional) (60.25 KB)
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  Operator Visiting Log (Optional) (122.26 KB)
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  Staffing Plan (170.33 KB)
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  Staffing Plan Excel Form (10.77 KB)
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  Menu Template (742.59 KB)
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  Emergency Phone List (11.65 KB)
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  Fire/Evacuation Drill Record updated 4-12-2017 (82.91 KB)
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  Backup Operator (145.54 KB)
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  Smoke Alarm & Carbon Monoxide Detector Monthly Test Log (299.36 KB)
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  Emergency Preparedness Plan updated 11.6.2017 (486.8 KB)

Resident Records Books:

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  Resident Records Books Cover Sheet (570.76 KB)
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  Resident Records Table of Contents - DD (117.22 KB)
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  Resident Records Table of Contents - APD and MHA (116.35 KB)
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  Residency Agreement Sample – Medicaid (95.84 KB)
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  Residency Agreement Sample – ElderPlace (101.88 KB)
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  Residency Agreement Sample – Private Pay (146.94 KB)
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  Classification Worksheet (171.32 KB)
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  ADL Definitions (105.2 KB)
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  APD and MHA Resident Screening Sheet (260.6 KB)
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  I/DD Resident Screening Sheet (353.44 KB)
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  Resident Re-Screening Sheet (112.88 KB)
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  Resident Information Sheet (113.21 KB)
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  Long Term Care Assessment Notice (94.36 KB)
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  Resident Personal Possessions Inventory (126.77 KB)
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  Residents' Bill of Rights (99.94 KB)
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  Nondiscrimination Policy (55.11 KB)
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  APD Resident Bed Rail Acknowledgment (49.64 KB)
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  Fillable APD Form 0556 Individual Consent to HCBS Limitations (IBL) (1.79 MB)
  • If file does not display in browser, download file
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  Non-fillable APD Form 0556 Individual Consent to HCBS Limitations (IBL) (972.81 KB)
  • Private-pay residents only
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  Notice of Involuntary Move (197.81 KB)
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  Activity Log (249.39 KB)
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  Mental Health Plan of Care 4/18/12 (113 KB)
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  APD-MHA Care Plan - older format (238.85 KB)
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  APD-MHA Care Plan updated 5-4-2017 (1 MB)
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  Commonly Used Abbreviations (15.36 KB)
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  Recommended Day Care Relative Care Request Form (20.94 KB)
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  Weekly Progress Notes (176.52 KB)
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  Incident Report (338.02 KB)
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  Individual Financial Record (110.4 KB)
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  Authorization to release confidential information (11.92 KB)
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  RN or Physician Monitoring Checklist (111.76 KB)
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  Resident Orientation to Fire & Safety in the Adult Care Home (103.38 KB)

Medication Administration Records:

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  Cover Sheet for MAR Book (37.51 KB)
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  Table of Contents For MAR Book (104.75 KB)
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  MAR-PRN Form (193.76 KB)
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  Physician order form updated 3.27.2018 (103.97 KB)
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  PRN Guideline (102.3 KB)
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  Controlled Substance Count Sheet (428.83 KB)
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  Medication Disposal Record Form (133.1 KB)
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  Commonly Used Medical Abbreviations (97.41 KB)
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  Balancing Test for I/DD (279.18 KB)
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  MAR Book - Packet of All Forms (906.11 KB)
• DEA Controlled Substance List

Exception Requests:

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  Exception Request General (36.83 KB)
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  Exception Request for Out Of Class Resident (92.68 KB)
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  Request for More than One Bedbound Resident (89.12 KB)
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  Interagency Placement Exception Request (398.1 KB)
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  Exception Request Ramps (98.04 KB)
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  Exception Request to 72 inch rule (98.36 KB)
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  Vacation or Absence From Home Request (246.35 KB)

Operator and Resident Manager Forms

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  Vaccination Religious Exception Form (31.74 KB)
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  Vaccination Medical Exception Form (35.09 KB)
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  Backup Operator (145.54 KB)
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  Provider Enrollment Agreement (260.82 KB)
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  Real Estate Form (117.83 KB)
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  Caregiver Employment Notification updated 8.1.2017 (127.93 KB)
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  Operator/Resident Manager Health History and Physician/Nurse Practitioner Statement (281.43 KB)
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  Proposed Operating Budget (812.42 KB)
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  Professional Character Reference (391.35 KB)

Self-Audit Tools

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  DD Adult Care Home Self Audit Tool (106.44 KB)
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  First Renewal Self Audit Tool (135.36 KB)
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  APD_MH Self-Audit Tool (107.02 KB)

Reclassification Request

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  APD Level 3 Reclassification Request (142.16 KB)
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  APD Class 3 Medical Professional Reference (72.05 KB)
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  DD Level 2B or 2M Reclassification Request (288.86 KB)
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  APD or MHA Class 2 Reclassification Request (144.01 KB)