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Resident Forms

Resident Forms

Resident Forms

Forms marked with a (*) are required and must be used unless prior written approval for a specific substitute form has been granted. All other forms on this page are intended to assist the licensee in demonstrating compliance with the record keeping requirements specified in the Adult Foster Care Licensing Rules. It is the responsibility of the licensee to copy and distribute each form as specified by statute.

Fire Safety

Appendix F Life Safety Code
E-Score Sample Packet
Finding the Home's Evacuation Difficulty Score
Finding the Staff Shift Score
Finding the Total Resident Score
Worksheet for Calculating Evacuation Difficulty Score
As an alternative to using the above Evacuation Score forms from 1985 which are required by R 330.1803, the department will accept the 2012 Life Safety Code Form “Worksheets for Determining Evacuation Capability”.  This version allows the user to fill them out electronically.   
Worksheets for Determining Evacuation Capability

Resident Care and Records

AFC Resident Medication Record BCAL-3267
AFC Sample Starter Packet
Appointment of Home for the Aged RESIDENT Authorized Representative BCAL-1610
Assessment Plan for AFC Residents BCAL-3265
Resident Care Agreement BCAL-3266(*)
Resident Funds Record Part 1 BCAL-2318(*)
Resident Funds Record Part 2 BCAL-2319(*)
Resident Health Care Appraisal BCAL-3947(*)
Resident Information and Identification Record BCAL-3483
Resident Register-BCAL-0535
Resident Weight Record BCAL-3485
AFC Incident/Accident Report BCAL-4607(*)