Forms
- Adult Care Facility Incident Report - Resident Comment DOH-5789 (PDF)
- 30 Day Notice of Termination DOH-5237 (PDF)
- ACF Resident Safety Plan Checklist DOH-5265 (PDF)
- Adult Care Facility Annual Financial Report Certificate of Operation DOH-5780 (PDF)
- Adult Care Facility Chronological Admission and Discharge Register DOH-5177 (DSS-3026) (PDF)
- Adult Care Facility Daily Resident Census Report DOH-5176 (DSS-2900) (PDF)
- Adult Care Facility Inventory of Resident Property DOH-5194 (DSS-3027) (PDF)
- Adult Care Facility Offering Personal Allowance Account DOH-5195 (DSS-2853) (PDF)
- Adult Care Facility Personal Allowance Ledger DOH-5193 (DSS-2854) (PDF)
- Adult Care Facility Personal Allowance Summary DOH-5196 (DSS-2855) (PDF)
- Adult Care Facility Waiver Request/Equivalency Notification Form (DOH-4235) (PDF)
- Adult Care Facilities Medical Equipment Waiver Checklist (DOH-4235A) (PDF)
- Adult Care Facilities Medical Equipment Waiver Addendum (DOH-4235B) (PDF)
- Adult Care Facility Mental Health Evaluation (DOH-5075) (PDF)
- Adult Care Facility Waiver Request/Equivalency Notification Form for Special Needs Assisted Living Residences (DOH-5257) (PDF)
- Affidavit (DOH-5773) (PDF)
- ALP Medical Evaluation DSS-4449C (PDF)
- Application for Renewal of Operating Certificate and Assisted Living Residence Biennial Fee (PDF)
- Assisted Living Program Interim Assessment DSS-4569 (PDF)
- Assisted Living Residence Medical Evaluation DOH-3122 (PDF)
- Assisted Living Program Medical Evaluation – Interim DSS-4568 (PDF)
- Assisted Living Program Nursing/Functional/Social Assessment DSS-4449D (PDF)
- Assisted Living Residence Resident Evaluation Form DOH-4397 Part B (PDF)
- Assisted Living Residence Resident Personal Data Form DOH-4397 Part A (PDF)
- Construction/Architectural Waiver Request DOH-5226 (PDF)
- Identifying Data DSS-4449B (PDF)
- Incident Report DOH-5175 (DSS-3123) (PDF)
- Medical Evaluation (Resident) DSS-3122 (PDF)
- Personal Data Sheet DSS-2949 (PDF)
- Plan of Correction (POC) Checklist DOH-5785 (PDF)
- Statement of Administrator Qualifications for Adult Care Facilities DOH-5259 (DSS-3233) (PDF)
