Record Keeping Forms

Facility records, resident records, medication administration records, exception requests, and required forms to own or work in an adult care home.

On this page

Business Records Book
Resident Records Books
Medication Administration Records
Exception Requests
Operator and Resident Manager Forms
Self-Audit Tools
Reclassification Request

Business Records Book

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Business Records Book Cover Sheet (12.87 KB)
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Business Records Table of Contents (116.99 KB)
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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)
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Adult Care Home Relocation Form (265.54 KB)
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Opioid Overdose Daily Checks Monthly Log (168.28 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 (238.33 KB)
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Residency Agreement Sample – ElderPlace (238.37 KB)
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Residency Agreement Sample – Private Pay (308.22 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)
If file does not display in browser, download file:

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Fillable APD Form 0556 Individual Consent to HCBS Limitations (IBL) (1.79 MB)
Private-pay residents only:
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Non-fillable APD Form 0556 Individual Consent to HCBS Limitations (IBL) (972.81 KB)
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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 (74.39 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)
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Resident Manager Exception Request (207.57 KB)
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Shift Managers Exception Request (96.14 KB)

Operator and Resident Manager Forms

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Provider Enrollment Agreement (260.82 KB)
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Real Estate Form (117.83 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)

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Resident Manager Change Request (103.96 KB)
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Sample Job Application (164.66 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 and BH Self Audit Tool (1.2 MB)

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)

Last reviewed November 14, 2024

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