Office of Licensing and Regulatory Oversight / Adult Foster Home
Renewal License Application
Type of Adult Foster Home (AFH) application (check one):
Licensee / Co-licensee / Resident manager / Shift caregiver
Part 1  to be completed by applicant
1 ― General information
A. / Applicant name:
B. / Phone:
Applicant’s home phone / Applicant’s cell number
C. / Adult Foster Home (AFH) address:
Street/City/State/ZIP code
D. / Mailing address
(if different):
Street/City/State/ZIP code
E. / Applicant’s email address: / check if none
Required for co-applicant
F. / Classification: What is the licensee classification of the AFH where you intend to work? (See OAR 411-050-0443 for specific classification criteria.)
Class 1 Class 2 Class 3
Note: The classification of your AFH license will be determined based on OAR 411-050-0443 for specific classification criteria.
G. / Capacity: How many AFH residents do you want to provide care for?
Number of day care persons:
Number of room and board residents:
Number of relatives needing care and services (including children):
H. / List the designated back-up licensee or resident manager who can act for you
in case of an emergency (required):
In what county is the back-up licensee or resident manager located?
Staffing plan: Identify all individuals you plan to use as substitute caregivers (Attach a separate piece of paper if necessary.)
Name / Typical weekly schedule / Phone number / Lives in your AFH?
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
2 ― Applicant information
A. / Emergency contact(s): Provide information for at least one contact.
Name / Phone number / Relationship to applicant
B. / Special skills: Please describe any professional licenses, languages spoken fluently and any other special skills you may have:
C. / Applicant history:
Since submitting your last application for an AFH license:
·  Have you 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 No
If yes, by whom? / Date:
Have you had a substantiated allegation of abuse or neglect? Yes No
If yes, by whom? / Date:
·  Have you or any AFH employee been placed on the Office of Inspector General’s (OIG) exclusion list or the General Services Administration (GSA) exclusion list? (Individuals on the OIG or GSA exclusion lists are prohibited from participating in any Federally funded health care program.) Yes No
D. / List all occupants in your home - Include all persons who live in or on the adult foster home premises. Examples: children, spouses, residents, live-in caregivers, room and board occupants and individuals living in a trailer on the AFH premises. (Attach a separate paper if necessary.)
Is this AFH your primary residence? Yes No
Occupant names / Relationship to applicant / Date of birth

Applicant information (continued)

3 ― Additional application requirements checklist
Attach or enclose copies of the following documents to your completed application. Check the corresponding boxes to indicate completion. Check the box marked NA if it does not apply to you.
Physician or Nurse Practitioner’s Statement ― Submit the completed, signed and dated original of the Department’s current Health History and Physician/Nurse Practitioner’s Statement (SDS 0903). (Required every third year or sooner if cause for health concern.)
NA
Background Check Request ― Enclose completed Background Check Request form
(DHS 0301AD), required for all persons 16 years of age and older who are occupants in or on the AFH premises, the licensed provider, resident manager, substitute caregiver, trainee or other employees, according to OAR 411-050-0412. NA
Application fee ― $20.00 per bed application fee (maximum $100.00)
Training/special qualifications ― Attach proof of required training and any special credentials. NA
Fire and Life Safety ― Required during the first year as available.
Basic First Aid ― Attach a copy of both sides of your certification ― required during the first year.
Cardiopulmonary Resuscitation (CPR) ― Attach a copy of both sides of your certification card if you currently have Adult CPR Certification (required annually).
Twelve hours of approved continuing education, up to four of those hours may be related to the business operation of the AFH ― Required after the first year of licensure.
4 ― Certification and signature
I 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:
·  failure to provide accurate information may result in the denial of my application;
·  my application is not complete until all required items have been submitted; and
·  an incomplete application will become void sixty (60) days from the date the application and fee are received by the Division.
I authorize the Department to verify the information provided on this application.
Applicant’s printed name / Date
Signature of applicant / Date

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SDS 0448C (10/12)