Website (801) 669-5370. Licensing Forms - Licensing Forms generally begin with "LIC". All forms are printable and downloadable. Claim for Payment of Cost of Unauthorized Medical Services, VA Form 10-583 (Fillable PDF) Claim for Miscellaneous Expenses. 1-800-273-TALK(8255) Utah Domestic Violence A "Download Fingerprint Form" button will appear after a background check form is authorized. Step 2: Once you have entered the editing page lic 500 community care licensing, you will be able to notice every one of the options available for your file at the upper menu. 3. Call: (801) 538-4242 Fields are being added to your document to make it really easy to fill, send and sign this PDF. Application for a Child Care Center License - LIC 200A. 1-855-323-DCFS(3237) However, most Office of Licensing staff have transitioned to telework and are not physically present in the building. Office of Accountability & Whistleblower Protection, Training - Exposure - Experience (TEE) Tournament, Indian Health Service/Tribal Health Program, CHAMPVA In-house Treatment Initiative (CITI), Training Courses and Educational Resources, Indian Health Services/Tribal Health/Urban Indian, Spina Bifida Health Care Benefits Program, Veterans Health Information Exchange Program, Durable Medical Equipment/ Pharmacy Requirements, War Related Illness & Injury Study Center, Clinical Trainees (Academic Affiliations), Call TTY if you COVID-19 Information and Resources. This document is locked as it has been sent for signing. This is to make the processes more efficient. This document has been signed by all parties. Step 1: The first thing will be to click the orange "Get Form Now" button. The Community Care Licensing (California) form is 1 page long and contains: Fill has a huge library of thousands of forms all set up to be filled in easily and signed. Child Care Licensing Bureau forms are available on the website as PDFs and Word Documents. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. Criminal Record Exemption Process - (including information regarding live scan). Listed below are the required forms to be completed by every child care facility owner and employee (age 18 and older) for the required background check per NRS 432A.175. Complete this form within 72 hours of calling in a suspicion of abuse or neglect. Human Services License. This is one piece of a historic $1.4 billion investment to expand access to quality, affordable child care for families. (The contract is fully executed when both parties have signed and dated the contract.). Our analysts can investigate your complaint more thoroughly when sufficient details are provided. If you change any of the sample forms, be sure they still contain all information required by rule. 1-801-587-3000 195 North 1950 West CareWeb Provider Connection Security Request Form. We are pleased to announce Child Care Licensing is now part of the newly consolidated Department of Health and Human Services (DHHS). The Word documents are fillable and are intended for electronic completion. Complete our forms to check eligibility, report incidents, or assessment worksheets, Our counselors and staff can help you with your requests or concerns. We license Foster Homes, Child Care Facilities, Human Services Programs, and Health Facilities, utilizing rules established with community support, to protect the dependent and vulnerable citizens of Utah. This is accomplished by: Establishing, monitoring, and assessing health and safety standards; Our mailing address is: Office of Licensing Designation Of Administrative Responsibility (Lic 308), Affidavit Regarding Client Cash Resources (Lic 400), Supplemental Financial Information (Lic 401a), Balance Sheet Supplemental Schedule (Lic 403a), Financial Information Release & Verification (Lic404). They treat my kids with respect and teach them great things. YP - The Real Yellow PagesSM - helps you find the right local businesses to meet your specific needs. Licensing & Providers. Send to someone else to fill in and sign. Use the links below to download these popular forms. 195 North 1950 West You can use the sample forms as they are or change them to meet your needs. Cancel at any time. Click the verification link in your email to start sending, signing and downloading documents. Big Brothers Big Sisters. (November 10, 2022), The fingerprint form is now generated through the provider's Child Care Licensing Portal. From Business: With our experienced staff and innovative programs unlike any other, our commitment to your child's future. Not the right email? Foster Family Homes. YP, the YP logo and all other YP marks contained herein are trademarks of YP LLC and/or YP affiliated companies. Listed below are samples of forms needed in the day-to-day operation of a licensed Nevada child care facility. 1-888-421-1100 Child Care Licensing. or certified family home or resource family and foster family agency, nor any copy of the complaint or any record published, Update it below and resend. Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF [opens in a new window] IHPP Referral Form for Authorization. Providers will then have to submit another background check form and fingerprints if they still want the covered individual's background check to be processed. Sexual Violence Crisis Line Although all of the information is the same, there may be some confusion about where to find everything on our newly designed CCL Website. Small Family Homes. Sexual Violence Crisis Line What I recommend to all of my clients is this: when we get a facility number assigned to the facility, submit a program design to Regional Center, this way both program designs will be going through the vetting process at the same time, and hopefully cross the finish line around the same time. Crisis Line & Mobile Outreach Team For additional information, please contact your California Child Care Licensing Program Regional Office. Temporary Management of Adult Community Care Facilities and RCFEs. Digital signatures are secured against your email so it is important to verify your email address. Then mail the document to the appropriate Office of Child Care Regional Licensing Office. Effective immediately, providers will not be notified when the Office of Background Processing staff receives a background check form without the required fingerprints. IMPORTANT: You must have Adobe Reader version 6.0 or later installed on your computer to view the documents on this site. ADA Access: Please contact facility for accessibility information. Please call with any questions or to connect with a Licensing staff member. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Once finished you can manually add any additional fields and signatures to the document by dragging them from the toolbar. Please attach any supporting documentation, photos, etc that may further assist with investigating your complaint. the application book is "LIC 281" Community Care Updates - Quarterly updates on items of interest and program changes you need to know about. During inspections, licensors will ask to see a government-issued photo ID (or a copy of that ID) for each covered individual. Search results are sorted by a combination of factors to give you a set of choices in response to your search criteria. listenButton1.onclick = function(){ Swimming Provisions - BCAL-1890, Child Care Home Record Requirements - BCAL-5040, Child Care Center Record Requirements - BCAL-5041. LIC 700. English. Group Homes. See reviews, photos, directions, phone numbers and more for Community Care Licensing locations in Provo, UT. this allows you to receive further information from the local licensing office about the status of this complaint. They must be completed manually. Required for new building/renovations only. 1-855-323-DCFS(3237) This is to verify the identity of the covered individual and to ensure all covered individuals passed the background check. 2. Email: dhslicensing@utah.gov, HotlinesAbuse/Neglect of Seniors and Adults with Disabilities You will recieve an email notification when the document has been completed by all parties. Technical Support Guides - Self-Assessment guides for use in maintaining compliance and understanding regulations. Hit enter to expand a main menu option (Health, Benefits, etc). Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF To access the menus on this page please perform the following steps. Community Care Licensing in Provo, UT. Payment/Insurance Accepted: Please contact provider for accepted forms of payment. Child Care Licensing Vision: Access to safe, healthy child care for Utah families. Multi-Agency State Office Building visit VeteransCrisisLine.net for more resources. One copy will be retained by the Operator and the other you may retain . If you do not have or did not receive a current . Reducing Barriers to Licensure for Military Families, Corporations, Securities & Commercial Licensing, Find / Verify a Licensed Professional or Business, Make a Complaint About a Licensed Professional or Business, Look Up Underground Storage Tank Information, Access the Online Liquor Ordering (OLO) System, Regulated Products, Professions, & Businesses Activities, Resources for Veterans & Military Families, https://dev.michigan.local/som/json?sc_device=json, Playground Inspection Certification Summary CCL-5047 Word, Go to An Online Resource for Skilled Immigrants, Medical Marijuana Program (MMMP) Patients & Caregivers, Learn About CRA Rules, Laws & Regulations, Find / Verify a CRA Licensed Professional or Business, Make a Complaint About a CRA Licensed Professional or Business, Track Marijuana Inventory - Statewide Marijuana Monitoring System (Metrc), Find Panel, Public Hearing & Workgroup Information, Find a Disciplinary Action Report or Document, Learn About CCL Rules, Laws & Regulations, Find / Verify a CCL Licensed Professional or Business, Make a Complaint About a CCL Licensed Professional or Business, Apply for / Renew a BCC License or Permit, Find / Verify a BCC Licensed Professional or Business, Make a Complaint About a BCC Licensed Professional or Business, Learn About Examinations & Continuing Education, Find / Verify a BCHS Licensed Professional or Business, Make a Complaint About a BCHS Licensed Professional or Business, Go to Corporations, Securities & Commercial Licensing, Find / Verify a CSCL Licensed Professional or Business, Make a Complaint About a CSCL Licensed Professional or Business, Contact the Michigan Liquor Control Commission, Local Government & Law Enforcement Resources, Go to Michigan Office of Administrative Hearings and Rules, Administrative Hearings Frequently Asked Questions, Request to Attend a Hearing (for Media Professionals), Go to Michigan Indigent Defense Commission, Learn About Continuing Legal Education (CLE), Make a Complaint or Inquiry About a Utility Provider, Compare Natural Gas Utilities Options (MI Gas Choice), Submit an Underground Utilities Locate Request (MISS DIG 811), Learn About Natural Gas & Pipeline Providers, Learn About Rules of Practice and Procedure, Find / Verify a BPL Licensed Professional or Business, Make a Complaint About a BPL Licensed Professional or Business, Michigan Automated Prescription System (MAPS), Find / Verify a UCC Licensed Professional or Business, Make a Complaint About a UCC Licensed Professional or Business, Go to Apply for / Renew a License or Permit, Go to Find / Verify a Licensed Professional or Business, Go to Make a Complaint About a Licensed Professional or Business, Go to Look Up Underground Storage Tank Information, Go to Look Up a Controlled Substance (MAPS), Go to Access the Online Liquor Ordering (OLO) System, Go to Look Up a Disciplinary Action Report, Go to Submit a Request for Information (FOIA), Go to Regulated Products, Professions, & Businesses Activities, Go to Requesting Information from LARA (FOIA), Go to Resources for Veterans & Military Families, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Spanish, Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 - Arabic, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - PDF, Michigan Child Care and Education Professional Development Record for Child Care Centers CCL-4591 - Word, Staffing Plan: Child Care Center CCL-5001 - PDF, Staffing Plan: Child Care Center CCL-5001 - Word, Staffing Plan: Child Care Center CCL-5001 Excel, Child Care License Designee CCL-5003 - PDF, Child Care License Designee CCL-5003 - Word, Certification of School Building Fire Safety Provisions CCL-5043 - PDF, Certification of School Building Fire Safety Provisions CCL-5043 - Word, Self-Certification of Transportation Provisions for Centers CCL-5044 - PDF, Self-Certification of Transportation Provisions for Centers CCL-5044 - Word, Volunteer Certification for Field Trip Transportation CCL-5046 - PDF, Volunteer Certification for Field Trip Transportation CCL-5046 - Word, Playground Inspection Certification Summary CCL-5047 - PDF, Family and Group Child Care Home Compliance Record - BCAL-4601, Preparing for Your License Renewal Fire Safety Inspection - BCAL-5048, Child Care Center Compliance Record, Part 1. 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