Office of Licensing and Regulatory Oversight / Adult Foster Home License Supplemental Application
Type of Adult Foster Home (AFH) application:
(Type or use ink to complete. Check one box per application.)
Co-applicant Resident manager Shift caregiver
Part 1─To be completed by licensee 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: Select the license classification you are requesting.
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.
2 ― Applicant information
A. / Your date of birth:
B. / Is the house where you are applying to operate an AFH your current primary residence where you live?” Yes No
If yes, should this application be approved for you to operate a AFH will this home continue to be your primary residence. Yes No
C. / Are you now, or have you ever been licensed or certified as a provider, resident manager or caregiver in an AFH? Yes No
If yes, what county? (If outside of Oregon, indicate where.)
Identify the agency or agencies that issued the AFH license(s) or other certificate(s):
DD (Developmental Disabilities)
APD (Aging and People with Disabilities, formerly Seniors and People with Disabilities)
DHS (Child Welfare, Self-Sufficiency, Child Care)
CountyOrdinance (Multnomah/Clackamas)
Mental Health
Veterans Administration / Other state:
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Applicant information (continued)D. / Emergency contact(s): Provide information for at least one contact.
Name / Phone number / Relationship to applicant
E. / 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 have you voluntarily surrendered a license or certificate while under sanction? Yes No
If yes, by whom? / Date:
Have you ever had a substantiated finding of abuse or neglect? Yes No
If yes, by whom? / Date:
Have you ever been placed on the Office of Inspector General’s (OIG) exclusion list or the General Services Administration’s (GSA) exclusion list? Yes No(Individuals on the OIG or the GSA exclusion lists are prohibited from participating in any federally funded health care program.)
F. / Education:
School / City
(Add country if
outside the USA) / Degree or number
of years / Year
G. / Special qualifications:
Registered nurse / License number:
Licensed practical nurse / License number:
Certified medical assistant / Certificate number:
Certified nursing assistant / Certificate number:
American sign language
Fluent in language(s) other than English
List languages:
Other:
H. / Training (attach verification):
Fire and Life Safety (within first year)
Basic First Aid (required within the first year – if you are currently certified in CPR attach a copy of both sides of your certification card)
Cardiopulmonary Resuscitation (CPR) (attach a copy of both sides of your certification card. CPR certification is required to be maintained after your first year of licensure)
Applicant information (continued)
- Medical professional references: If you are requesting to operate or work in a
Class 3 AFH, identify two medical professionals on the following page who have direct knowledge of your ability and past experience as a caregiver.
(Note: Medical professional means licensed health care professionals such as a medical doctor, osteopathic physician, nurse practitioner, registered nurse, physical therapist, occupational therapist or respiratory therapist.)
Do not include the name of your personal health care provider unless he or she has direct knowledge of your experience as a caregiver.Name and title of medical professional / Phone number
Mailing address (Street/P.O. Box/City/State/ZIP code)
Name and title of medical professional / Phone number
Mailing address (Street/P.O. Box/City/State/ZIP code)
K. / List all occupants in your home:Include all persons who live in your adult foster home. Examples: children, spouses, residents, live-in caregivers, room and board occupant. (Attach additional pages if necessary.)
AFH occupant names: / Relationship to applicant: / Date of birth:
J. / Work history: List your caregiving experience for the last five years starting with your most current job (attach a separate sheet of paper if needed).
Contact person:
Name of business: / Phone:
Mailing address:
Street/P.O. Box/City/State/ZIPcode
Your job title:
Start date (month/year): / End date (month/year):
Work history (continued)
Hours worked per week:
Did you provide care to persons who were dependent in 3 or more ADLs? Yes No
Describe your job duties:
Contact person:
Name of business: / Phone:
Mailing address:
Street/P.O. Box/City/State/ZIP code
Your job title:
Start date (month/year): / End date (month/year):
Hours worked per week:
Did you provide care to persons who were dependent in 3 or more ADLs? Yes No
Describe your job duties:
Contact person:
Name of business: / Phone:
Mailing address:
Street/P.O. Box/City/State/ZIP code
Your job title:
Start date (month/year): / End date (month/year):
Hours worked per week:
Did you provide care to persons who were dependent in 3 or more ADLs? Yes No
Describe your job duties:
Contact person:
Name of business: / Phone:
Mailing address:
Street/P.O. Box/City/State/ZIP code
Your job title:
Start date (month/year): / End date (month/year):
Hours worked per week:
Work history (continued)
Did you provide care to persons who were dependent in 3 or more ADLs? Yes No
Describe your job duties:
Contact person:
Name of business: / Phone:
Mailing address:
Street/P.O. Box/City/State/ZIP code
Your job title:
Start date (month/year): / End date (month/year):
Hours worked per week:
Did you provide care to persons who were dependent in 3 or more ADLs? Yes No
Describe your job duties:
K. / General references: Provide three references that are not related to you. Current or potential AFH licensees and coworkers of the applicant are not eligible to be a general reference.
Name / Phone number
Mailing address − Street/P.O. Box/City/State/ZIP code
Name / Phone number
Mailing address − Street/P.O. Box/City/State/ZIP code
Name / Phone number
Mailing address − Street/P.O. Box/City/State/ZIP code
3―Additional application requirements checklist
Include copies of the following documents with your completed application. Check the corresponding boxes to indicate completion or check the box marked N/A if it does not apply
to you.
Physician or Nurse Practitioner’s Statement: Submit the completed, signed and dated original of the Department’scurrent Health History and Physician/Nurse Practitioners Statement (SDS 0903).
Background check verification: Enclose verification of an approved background check for all persons 16 years of age and older who are occupants on the AFH premises, the licensed provider, resident manager, shift caregiver substitute caregiver, trainee or other employees and according to
OAR 411-050-0412. This verification must be less than one (1) year old.
Training: Attach proof of required training and any special credentials, as identified on page 2(G) and (H).
Orientation: Attach proof of attending an adult foster home orientation. The orientation must have been provided by the local licensing office.
$10.00 fee: If applying for resident manager or shift caregiver during the period the AFH license covers (fee is not required if submitted with initial or renewal application). N/A
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 in sixty (60) days from the date the application and fee are received by the Division.
Applicant’s printed name / Date
Signature of applicant / Date
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