On-line Forms and Publications I - L

I | J | K | 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

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

L Forms

• LIC 01A (6/23) - Resource Family Application
• LIC 01C (7/16) - Resource Family Application-Confidential
• LIC 03 (7/23) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only
• LIC 05A (8/21) - Resource Family Approval Certificate
• LIC 08 (2/24) - Intensive Services Foster Care Unit (ISFC) Written Assessment of Risk and Compatibility
• LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP)
• LIC 122 (1/08) - Release Of Information
• LIC 125 (3/21) - Entrance Checklist - Child Care Centers
• LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes
• LIC 165 (8/07) - Board Of Directors Statement
• LIC 184 (5/00) - Notification Of Incomplete Application
• LIC 184B (3/23) - Notification Of Incomplete Application - Family Child Care Home
• LIC 184C (3/23) - Notification Of Incomplete Application (NOIA) Child Care Centers - Pre-30-Day NOIA
• LIC 184D (3/23) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA
• LIC 184E (3/23) - 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 (1/22) - Child Abuse Central Index Check For County Licensed Facilities
• LIC 198B (9/23) - Out-Of-State Child Abuse/Neglect Report Request
• LIC 200 (2/24) - 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 (1/25) - Application for a Child Care Center License
• LIC 201F (2/01) - Annual License Fee Notice - County
• LIC 215 (12/22) - Applicant Information
• LIC 215TM (11/18) - Temporary Manager Candidate List Application Information
• LIC 216TM (11/18) - Temporary Manager Appointment Applicant Information
• LIC 279 (2/23) - Application For A Family Child Care Home License
• LIC 279A (6/24) - License Application And Instructions For Family Child Care Homes
• LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License
• LIC 281 (6/24) - Application Instructions for A Facility License
• LIC 281A (2/24) - License Application And Instructions For Child Care Centers
• LIC 281D (2/24) - Application And Supporting Documentation Checklist Foster Family Agency
• LIC 281E (12/24) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program
• LIC 282 (1/22) - Affidavit Regarding Liability Insurance For Family Child Care Home
• LIC 300A (10/23) - Removal Confirmation - Exemption Needed
• LIC 300B (11/23) - 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 301E (10/22) - 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 (2/22) - 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 (2/22) - 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 (3/24) - Civil Penalty Assessment (Unlicensed Facility)
• LIC 421BG (5/19) - Civil Penalty Assessment – Caregiver Background Check
• LIC 421CC (6/22) - Civil Penalty Assessment – Child Care
• LIC 421D (ASC) (6/17) - Civil Penalty Assessment – Death/Serious Bodily Injury/Physical Abuse (ASC)
• LIC 421D (CC) (8/22) - 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 (6/24) - Health Screening Report - Facility Personnel
• LIC 507 (1/00) - Facilities Staff Work Schedule
• LIC 508 O-O-S (9/23) - Out-Of-State Disclosure
• LIC 508D (10/23) - Out-Of-State Disclosure And Criminal Record Statement
• LIC 601 (8/08) - Identification And Emergency Information
• LIC 602 (7/22) - Physician's Report For Community Care Facilities
• LIC 602A (4/25) - Medical Assessment for Residential Care Facilities for the Elderly
• LIC 603 (6/22) - 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 (7/22) - Release Of Client/Resident Medical Information
• LIC 606 (8/18) - Residential Care Facility For The Elderly Disclosure Worksheet
• LIC 610 (11/23) - Emergency Disaster Plan For Child Care Centers
• LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes
• LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes)
• LIC 610D (12/21) - 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 (5/25) - Personal Rights – Child Care Centers
• LIC 613B (6/22) - 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 (3/25) - 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 (12/22) - Law Enforcement Contact Report
• LIC 625 (10/24) – Appraisal/Needs and Services Plan
• LIC 627 (9/08) - Consent For Emergency Medical Treatment - Child Care Centers Or Family Child Care Homes
• 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 809 (9/23) - Facility Evaluation Report
• LIC 811 (8/06) - Confidential Names
• LIC 812 (8/06) - Detail Supportive Information
• LIC 813 (5/24) - 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 (Residential)
• LIC 859 (8/06) - Review of Staff/Volunteer
• LIC 907 (5/00) - Transmittal For Processing
• LIC 957 (10/99) - Complaint Control Log
• LIC 972 (5/00) - Individual Waiver/Exception Log
• 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 999 (3/99) - Facility Sketch (Floor Plan)
• LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home
• 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 (3/25) - Statement of Facts Summary Sheet
• LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License
• LIC 9040 (10/05) - Child Care Facility Roster
• LIC 9052 (1/22) - Notice Employee Rights
• LIC 9054 (3/99) - Local Fire Inspection Authority Information
• LIC 9058 (3/22) - 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 9106A (9/24) - Short-Term Residential Therapeutic Program
• LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse
• LIC 9111 (12/99) - Noncompliance Conference Summary
• LIC 9112 (9/21) - Facility Compliance Plan
• LIC 9118 (6/21) - Facility Inspection Checklist Checklist Child Care Centers
• LIC 9119 (10/22) – Facility Inspection Checklist Group Homes
• LIC 9119 AA (7/22) - Facility Inspection Checklist Adoption Agency
• LIC 9119 CCH (11/22) - Facility Inspection Checklist Community Crisis Home
• LIC 9119 CN (8/22) - Facility Inspection Checklist Crisis Nurseries
• LIC 9119 CTF (1/22) – Facility Inspection Checklist Community Treatment Facility
• LIC 9119 EBSH (4/22) - Facility Inspection Checklist Enhanced Behavioral Supports Homes
• LIC 9119 TrSCF (12/22) - Facility Inspection Checklist Transitional Shelter Care Facility
• LIC 9119 YHPC (4/22) - Facility Inspection Checklist Youth Homelessness Prevention Center
• LIC 9120A (2/20) - Licensed Facility Inspection Checklist Adult Care Facilities
• LIC 9121 (7/21) - Facility Visit Checklist Family Child Care
• 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 (5/23) - Foster Family Agency Program Statement
• LIC 9139 (3/23) - Renewal Of Continuing Education Course Approval - Administrator Certification Program
• LIC 9140 (3/24) - Request For Course Approval - Administrator Certification Program
• LIC 9140A (3/23) - Request to Add or Replace Instructor
• LIC 9141 (6/23) - Vendor Application/Renewal - Administrator Certification Program
• LIC 9142A (3/23) - 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 (7/22) - Telecommunications Device Notification
• LIC 9163 (1/25) - Request Live Scan Service - Community Care Licensing
• LIC 9163B (11/22) - Request Live Scan Service - Long Term Care OMBUDSMAN
• LIC 9165 (4/22) - Board Of Director Statement
• LIC 9166 (2/01) - Nebulizer Care Consent/Verification (Child Care Facilities)
• LIC 9172 (8/01) - Functional Capability Assessment
• LIC 9182 (11/23) - Criminal Background Clearance Transfer Request
• LIC 9186 (2/01) - Client Death Report
• LIC 9187 (7/00) - Child Care Client Death Report
• LIC 9188 (11/23) - Criminal Record Exemption Transfer Request
• LIC 9200 (9/11) - Pre-Licensing Facility Evaluation Checklist
• LIC 9211 (9/21) - 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 (5/23) - Application for Administration Certification - Administrator Certification Program
• LIC 9216 (3/17) - Complaint And Type A Violation Log
• LIC 9217 (5/22) - 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 (5/22) - Parent Consent For Administration Of Medications And Medication Chart
• LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities
• 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 (7/21) - Licensing Program Manager (LPM) Checklist For Complaint Review
• LIC 9230 (7/21) - Licensing Program Analyst (LPA) Checklist For Complaint Review
• LIC 9233 (7/20) – Facility Inspection Checklist Foster Family Agencies
• LIC 9234 (5/23) – Entrance Checklist Foster Family Agency
• LIC 9235 (10/22) – Facility Inspection Checklist Short – Term Residential Therapeutic Program
• LIC 9236 (6/23) – Entrance Checklist Short – Term Residential Therapeutic Program
• LIC 9237 (7/20) – Facility Inspection Checklist Transitional Housing Placement Program
• LIC 9238 (5/23) – Entrance Checklist Transitional Housing Placement Program
• LIC 9239 (5/23) – Entrance Checklist Group Home
• LIC 9239 AA (12/22) – Entrance Checklist Adoption Agency
• LIC 9239 CCH (3/23) - Entrance Checklist - Community Crisis Homes
• LIC 9239 CN (3/23) - Entrance Checklist - Crisis Nurseries
• LIC 9239 CTF (3/23) - Entrance Checklist Community Treatment Facility
• LIC 9239 EBSH (3/23) - Entrance Checklist - Enhanced Behavioral Supports Homes
• LIC 9239 TrSCF (3/23) - Entrance Checklist - Transitional Shelter Care Facility
• LIC 9239 YHPC (3/23) - Entrance Checklist - Youth Homelessness Prevention Center
• LIC 9240 (6/23) – 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
• LIC 9263 (8/23) – Form 1-1: Resident Population
• LIC 9264 (3/21) – Form 1-2: Annual Provider Fee
• LIC 9265 (6/21) – Form 5-1: Long-Term Debt Incurred In A Prior Year (Including Balloon Debt)
• LIC 9266 (3/21) – Form 5-2: Long-Term Debt Incurred During Fiscal Year (Including Balloon Debt)
• LIC 9267 (3/21) – Form 5-3: Calculation Of Long-Term Debt Reserve Amount
• LIC 9268 (6/21) – Form 5-4: Calculation Of Net Operating Expenses
• LIC 9269 (3/21) – Form 5-5: Annual Reserve Certification
• LIC 9270 (9/22) – Form 7-1: Report On CCRC Monthly Care Fees
• LIC 9271 (6/21) – Form 9-1: Calculation Of Refund Reserve Amount
• LIC 9272 (11/21) – Annual Report Checklist
• LIC 9273 (7/23) – Continuing Care Retirement Community Disclosure Statement
• LIC 9274 (11/21) – Key Indicators Report
• LIC 9275 (6/21) - External Water Sampler Self-Certification Form
• LIC 9276 (7/21) – Child Care Center Sampling Checklist Form
• LIC 9277LUA (8/23) - Guardian Licensee User Access Form
• LIC 9279 (10/21) - Pre-licensing Entrance Checklist - Child Care Centers
• LIC 9280 (10/21) - Pre-licensing Entrance Checklist - Family Child Care Homes
• LIC 9282 (6/23) – Residential Infection Control Plan - Adult Residential Facilities, Enhanced Behavioral Supports Homes, Community Crisis Homes, Residential Care Facilities for the Elderly, Residential Care Facilities for the Chronically Ill, and Social Rehabilitation Facilities
• LIC 9283 (6/23) - Infection Control Plan - Adult Day Programs