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Forms - Alphabetic List
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On-line Forms and Publications I - L
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I Forms
ICPC 100A Instructions (7/20) – Instructions For Completing Form ICPC — 100A Interstate Compact On The Placement Of Children Request
ICPC 100A (11/20) –Interstate Compact On The Placement Of Children Request
ICPC 100B Instructions (7/20) – Instructions For Completing Form ICPC — 100B Interstate Compact Report On Child’s Placement Status
ICPC 100B (7/20) – Interstate Compact On The Placement Of Children Report On Child’s Placement Status
IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006)
IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From Workweek Limits For Extraordinary Circumstances (Exemption 2) - Provider
IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits
IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Provider’s Expiration Of Exemption From Workweek Limits
K Forms
KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds
KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program
KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents
KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement
KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form
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L Forms
LIC 00 (8/17) - Conversion to Resource Family: Release of Information
LIC 00A (2/17) - Conversion - Resource Family Application
LIC 01A (7/19) - Resource Family Application
LIC 01C (7/16) - Resource Family Application-Confidential
LIC 03 (7/19) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only
LIC 05A (8/19) - Resource Family Approval Certificate
LIC 12 (9/19) - Resource Family Approval Document Alternative Plan (DAP)
LIC 102 (9/99) - Sanitation Inspection Request
LIC 107 (9/00) - Applicant Fingerprint Follow-Up Request
LIC 122 (1/08) - Release Of Information
LIC 165 (8/07) - Board Of Directors Statement
LIC 178 (12/15) - Deficiency/Penalty Review
LIC 184 (5/00) - Notification Of Incomplete Application
LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application
LIC 184B (1/14) - Notification Of Incomplete Application - Family Child Care Home
LIC 184C (1/14) - Notification Of Incomplete Application (NOIA) Child Care Centers - Pre-30-Day NOIA
LIC 184D (1/14) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA
LIC 184E (8/19) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status
LIC 185 (5/99) - Contact Sheet
LIC 186A (10/04) - Orientation Meeting Family Child Care Home
LIC 192 (7/03) - Notification Of Initial Application Denial
LIC 195 (8/19) - Notice Of Operation In Violation Of Law
LIC 195A (8/19) - Notice Of Operation In Violation Of Law - Family Child Care Home
LIC 198 (2/01) - Child Abuse Central Index Check For County Licensed Facilities
LIC 198B (3/20) - Out-Of-State Child Abuse/Neglect Report Request
LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License
LIC 200TM (6/18) - Temporary Manager Application For Provisional License
LIC 200A (2/17) - Application for a Child Care Center License
LIC 201F (2/01) - Annual License Fee Notice - County
LIC 215 (7/04) - Applicant Information
LIC 215TM (11/18) - Temporary Manager Candidate List Application Information
LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information
LIC 229 (9/99) - Certificate Of Approval (For Certified Family Homes)
LIC 279 (2/09) - Application For A Family Child Care Home License
LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes
LIC 279B (10/05) - Current Children In Your Home - Application For A Family Child Care Home License
LIC 281 (9/04) - Application Instructions for A Facility License
LIC 281A (1/07) - License Application And Instructions For Child Care Centers
LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency
LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program
LIC 282 (8/08) - Affidavit Regarding Liability Insurance For Family Child Care Home
LIC 283 (4/10) - Foster Family Home Application
LIC 283A (12/07) - Foster Family Home Application Instructions
LIC 300A (9/03) - Removal Confirmation - Exemption Needed
LIC 300B (9/03) - Removal Confirmation - Denial
LIC 300C (9/03) – Removal Confirmation – Rescinded
LIC 300D (9/03) - Removal Confirmation – Non-Exemptible
LIC 300E (12/03) - Removal Confirmation - County
LIC 301 (8/99) - Reference Request
LIC 301A (8/07) - Reference Request - Adoption Facilitator
LIC 301B (8/07) - Reference Request - Long-Term Care Ombudsman Program
LIC 301E (7/03) - Reference Request - Exemption
LIC 306 (3/01) - Reporting Requirements By Licensees To The State Department Of Social Services
LIC 308 (11/02) - Designation Of Facility Responsibility
LIC 309 (6/01) (PUBLIC) - Administrative Organization
LIC 311A (3/07) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children
LIC 311B (4/05) - Records To Be Maintained By The Facility - Group Homes
LIC 311C (4/05) - Records To Be Maintained At The Facility - Adult Residential
LIC 311D (3/07) - Forms/Records To Keep In Your Family Child Care Home
LIC 311E (4/05) - Records To Be Maintained At The Facility - Small Family Home And Foster Family Home
LIC 311F (4/05) - Records To Be Maintained At The Facility - Residential Care Facility For The Elderly
LIC 313 (12/01) - Evidence Of Program Consultant
LIC 400 (1/99) - Affidavit Regarding Client/Resident Cash Resources
LIC 401 (3/01) - Monthly Operating Statement
LIC 401A (3/99) - Supplemental Financial Information
LIC 402 (8/04) - Surety Bond
LIC 403 (7/11) - Balance Sheet
LIC 403A (9/11) - Balance Sheet Supplemental Schedule
LIC 404 (7/99) - Financial Information Release And Verification
LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources
LIC 406 (5/13) - Client/Resident Cash Sheet
LIC 420 (4/99) - Budget Information
LIC 421A (7/11) - Civil Penalty Assessment (Unlicensed Facility)
LIC 421BG (5/19) - Civil Penalty Assessment – Caregiver Background Check
LIC 421CC (8/17) - Civil Penalty Assessment – Child Care
LIC 421D(ASC) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (ASC)
LIC 421D(CC) (6/17) - Civil Penalty Assessment – Death/Serious Injury/Physical Abuse (Child Care)
LIC 421D(CRP) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (CRP)
LIC 421FC (7/17) - Civil Penalty Assessment – Failure To Correct And Repeat Violations
LIC 421IM (7/17) - Civil Penalty Assessment – Immediate $500 And Repeat Violations
LIC 422 (9/11) - Notice Of Civil Penalties Due
LIC 422A (10/11) - Civil Penalty Ledger
LIC 424 (1/03) - Record Of Client's Cash Resources For Change Of Licensee
LIC 500 (11/03) - Personnel Report
LIC 501 (3/99) - CCL/Personnel Record
LIC 503 (3/99) - Health Screening Report - Facility Personnel
LIC 507 (1/00) - Facilities Staff Work Schedule
LIC 508 (7/20) - Criminal Record Statement & Out-Of-State Disclosure
LIC 508 O-O-S (2/20) - Out-Of-State Disclosure
LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator
LIC 508B (3/11) - Criminal Record Statement - Long-Term Care Ombudsman Program
LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement
LIC 601 (8/08) - Identification And Emergency Information
LIC 602 (7/11) - Physician's Report For Community Care Facilities
LIC 602A (8/11) - Physician's Report For Residential Care Facilities For The Elderly (RCFE)
LIC 603 (9/99) - Preplacement Appraisal Information
LIC 603A (7/99) - Resident Appraisal
LIC 604 (10/05) - Admission Agreement Guide For Residential Facilities
LIC 604A (2/05) - Admission Agreement For Residential Care Facilities For The Elderly
LIC 605A (5/00) - Release Of Client/Resident Medical Information
LIC 606 (8/18) - Residential Care Facility For The Elderly Disclosure Worksheet
LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers
LIC 610A (6/05) - Emergency Disaster Plan For Family Child Care Homes
LIC 610B (6/02) - Emergency Plan For Foster Family Homes
LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes)
LIC 610D (10/03) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities
LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly
LIC 613 (12/02) - Personal Rights Adult Residential Care Facilities
LIC 613A (8/08) - Personal Rights - Child Care Centers
LIC 613B (9/19) - Personal Rights Children’s Residential Facilities
LIC 613C (1/19) - Personal Rights Of Residents In Publicly Operated Residential Care Facilities For The Elderly
LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly
LIC 621 (4/99) - Client/Resident Personal Property And Valuables
LIC 622 (9/19) - Centrally Stored Medication And Destruction Record
LIC 622A (6/17) - Medication Administration Record (MAR)
LIC 622B (5/17) - Psychotropic Medication Administration Record (MAR)
LIC 623 (5/01) - Group Planned Activities
LIC 624 (4/99) - Unusual Incident/Injury Report
LIC 624A (7/99) - Death Report
LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home
LIC 624 LE (4/17) - Law Enforcement Contact Report
LIC 625 (11/19) – Appraisal/Needs and Services Plan
LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes
LIC 627A (9/08) - Consent To A Medical Examination
LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities
LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities
LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes
LIC 701 (8/08) - Physician's Report - Child Care Centers
LIC 701A (9/00) - Gastrostomy - Tube Care: Physician's Checklist (Child Care Facilities)
LIC 701B (9/00) - Gastrostomy - Tube Care Consent/Verification (Child Care Facilities)
LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report
LIC 808 (12/20) – Plan For Epidemic Outbreak Specific to COVID – 19 Mitigation Plan Report
LIC 809 (12/15) - Facility Evaluation Report
LIC 811 (8/06) - Confidential Names
LIC 812 (8/06) - Detail Supportive Information
LIC 813 (11/99) - Facility Photography Report
LIC 855 (9/00) - Declaration
LIC 856A (3/21) - Complaint Intake Notification
LIC 856B (3/21) - Complaint Determination Notification - Substantiated
LIC 856C (3/21) - Complaint Determination Notification - Unsubstantiated
LIC 856D (3/21) - Complaint Determination Notification - Unfounded
LIC 857 (8/06) - Children's Record Review
LIC 858 (10/99) - Client/Resident Records Review
LIC 858A (7/00) - Additional Child Records Review For Specialized Foster Care Homes
LIC 859 (8/06) - Review of Staff/Volunteer
LIC 860C (12/02) - Facility Review Index Foster Family Homes
LIC 861 (1/03) - Prelicensing In-Home Interview
LIC 907 (5/00) - Transmittal For Processing
LIC 957 (10/99) - Complaint Control Log
LIC 972 (5/00) - Individual Waiver/Exception Log
LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms)
LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones)
LIC 981 (10/99) - Weekly Itinerary
LIC 986A (10/99) - Notice Of Revocation Action
LIC 989 (11/02) - Information Request
LIC 989A (3/17) - Non-Confidential Records Request Form
LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights
LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights
LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion)
LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement)
LIC 995D (5/03) - Family Child Care Home Explanation Of Removal/Exclusions And Reinstatement
LIC 995E (10/09) - Important Information For Parents
LIC 995F (10/09) - Caregiver Background Check Information
LIC 996 (5/99) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Federal Property
LIC 996A (5/01) - Agreement For Licensure Of Community Care Facility/Child Care Facility On Indian Reservations
LIC 997 (10/99) - Agreement By Licensee/Applicant On Federal Property
LIC 997A (4/01) - Agreement By Licensee/Applicant On Indian Reservations
LIC 999 (3/99) - Facility Sketch (Floor Plan)
LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home
LIC 9011A (4/05) - County Licensing Administrative Action Personnel Flagging Attachment
LIC 9011B (5/05) - CDSS Licensing Administrative Action Personnel Flagging Attachment
LIC 9015 (9/00) - Legal Case Transmittal
LIC 9020 (5/17) - Register Of Facility Clients/Residents
LIC 9020A (6/17) - Register Of Facility Residents - Residential Care Facilities For The Elderly
LIC 9029A (1/08) - Statement Of Facts Summary Sheet
LIC 9029B (7/09) - Statement Of Facts Preparation Checklist
LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License
LIC 9040 (10/05) - Child Care Facility Roster
LIC 9052 (3/03) - Notice Employee Rights
LIC 9054 (3/99) - Local Fire Inspection Authority Information
LIC 9058 (12/15) - Applicant/Licensee Rights
LIC 9059 (5/99) - Personal Property Procedures
LIC 9060 (2/00) - Resident Theft And Loss Record
LIC 9092 (2/11) - Fire Pre-Inspection/Consultation Request
LIC 9095 (6/99) - Evaluation Of Teacher Qualifications
LIC 9096 (2/00) - Evaluation Of Director Qualifications
LIC 9098 (4/09) - Proof Of Correction(s)
LIC 9099 (12/16) - Complaint Investigation Report
LIC 9102TA (2/19) - Advisory Notes - Technical Assistance
LIC 9102TV (2/19) - Advisory Notes - Technical Violation
LIC 9106 (11/19) - Group Home Program Statement General Instructions
LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse
LIC 9111 (12/99) - Noncompliance Conference Summary
LIC 9112 (9/20) - Facility Compliance Plan
LIC 9118 (11/03) - Facility Visit Checklist Child Care Centers And Infant Centers
LIC 9119 (7/20) – Facility Inspection Group Homes
LIC 9120A (2/20) - Licensed Facility Inspection Checklist Adult Care Facilities
LIC 9121 (11/03) - Facility Visit Checklist Family Child Care
LIC 9122 (11/03) - Facility Visit Checklist Foster Family Home
LIC 9122A (7/20) – Facility Inspection Checklist Small Family Home
LIC 9123 (2/20) - Facility Inspection Checklist - Residential Care Facility For The Elderly
LIC 9128 (6/99) - Foster Family Agency Program Statement
LIC 9139 (11/16) - Renewal Of Continuing Education Course Approval - Administrator Certification Program
LIC 9140 (11/16) - Request For Course Approval - Administrator Certification Program
LIC 9140A - Request to Add or Replace Instructor
LIC 9142A - Roster of Participants
LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC)
LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form
LIC 9150 (8/14) - Parent Notification - Additional Children in Care
LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home
LIC 9158 (11/04) - Telecommunications Device Notification
LIC 9163 (12/15) - Request Live Scan Service - Community Care Licensing
LIC 9163B (7/11) - Request For Live Scan Service - Long Term Care Ombudsman
LIC 9165 (2/99) - Board Of Director Statement
LIC 9166 (2/01) - Nebulizer Care Consent/Verification (Child Care Facilities)
LIC 9172 (8/01) - Functional Capability Assessment
LIC 9182 (11/15) - Criminal Background Clearance Transfer Request
LIC 9185 (8/08) - Foster Family Agency Certified Home
LIC 9186 (2/01) - Client Death Report
LIC 9187 (7/00) - Child Care Client Death Report
LIC 9188 (11/15) - Criminal Record Exemption Transfer Request
LIC 9198 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Staff Qualifications/Records Module Child Care Centers
LIC 9199 (7/01) - Modified Comprehensive Visit Licensee Self-Assessment Children's Records Module Child Care Centers
LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist
LIC 9201 (10/01) - Annual Regulation Compliance Checklist
LIC 9210 (5/06) - Quarterly County Exemption Report
LIC 9211 (1/08) - Request For Inactive Child Care License Status
LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care
LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative
LIC 9214 (1/21) - Application for Administration Certification - Administrator Certification Program
LIC 9216 (3/17) - Complaint And Type A Violation Log
LIC 9217 (3/05) - Pre-Licensing Readiness Guide - Family Child Care Home
LIC 9219 (3/16) - Crisis Nursery Monthly Report
LIC 9219A (3/16) - Crisis Day Care Sign-In
LIC 9221 (8/08) - Parent Consent For Administration Of Medications And Medication Chart
LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities
LIC 9223 (4/17) - Child Care Advocate Program
LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports
LIC 9225 (4/10) - Pre-Placement Questionnaire
LIC 9226 (5/18) - Request For Training Approval: Mandated Child Abuse Reporter Training
LIC 9227 (8/20) - Individual Infant Sleeping Plan
LIC 9229 (3/20) - Licensing Program Manager (LPM) Checklist For Complaint Review
LIC 9230 (3/20) - Licensing Program Analyst (LPA) Checklist For Complaint Review
LIC 9233 (7/20) – Facility Inspection Checklist Foster Family Agencies
LIC 9234 (7/20) – Entrance Checklist Foster Family Agency
LIC 9235 (7/20) – Facility Inspection Checklist Short – Term Residential Therapeutic Program
LIC 9236 (7/20) – Entrance Checklist Short – Term Residential Therapeutic Program
LIC 9237 (7/20) – Facility Inspection Checklist Transitional Housing Placement Program
LIC 9238 (7/20) – Entrance Checklist Transitional Housing Placement Program
LIC 9239 (7/20) – Entrance Checklist Group Home
LIC 9240 (7/20) – Entrance Checklist Small Family Home
LIC 9241 (2/20) - Entrance Checklist Adult Care Facilities
LIC 9242 (9/19) - Entrance Checklist Residential Care Facilities For The Elderly
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