Right Column
On-line Forms and Publications I - L
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I Forms
- ICPC 100A (10/03) - Interstate Compact Placement Request
- ICPC 100B (8/99) - Interstate Compact Report On Child's Placement Status
- ILP 1 (3/10) - Independent Living Program Annual Report And Plan Federal Fiscal Year (FFY) 2008
K Forms
- KG 1 (8/02) - Kin-GAP Mutual Agreement For 18 Year Olds
- KG 2 (8/02) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (Kin-GAP) Program
- KG 2A (3/01) - Rights, Responsibilities And Other Important Information (For The KinGAP) Program
L Forms
- 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 (5/99) - Penalty Review
- LIC 184 (5/00) - Notification Of Incomplete Application
- LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application
- LIC 185 (5/99) - Contact Sheet
- LIC 186A (10/04) - Orientation Meeting Family Child Care Home
- LIC 192 (7/03) - Notiification Of Initial Application Denial
- LIC 195 (6/10) - Notice Of Operation In Violation Of Law
- LIC 195A (6/10) - 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 198A (9/07) - Child Abuse Central Index Check For State Licensed Facilities
- LIC 198B (7/08) - Out-Of-State Child Abuse/Neglect Report Request
- LIC 200 (7/08) - Application For A Community Care Facility or Residential Care Facility For The Elderly License
- LIC 200A (6/08) - Application for a Child Care Center License
- LIC 201F (2/01) - Annual License Fee Notice - County
- LIC 215 (7/04) - 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 (1/07) - 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 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 (07/03) - Reference Request - Exemption
- LIC 306 (03/01) - Reporting Requirements By Licensees To The State Department Of Social Services
- LIC 308 (11/02) - Designation Of Facility Responsibility
- LIC 309 (6/01) - 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 (11/02) - Balance Sheet
- LIC 403A (12/02) - 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 420 (4/99) - Budget Information
- LIC 421 (5/06) - Civil Penalty Assessment
- LIC 421A (3/05) - Civil Penalty Assessment (Unlicensed Facility)
- LIC 421B (5/06) - Civil Penalty Assessment - Immediate
- LIC 422 (10/03) - Notice Of Civil Penalties Due
- LIC 422A (5/01) - Civil Penalty Ledger Payment, Reduction, Or Waiver Record
- LIC 424 (1/03) - Record Of Clients 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 (10/09) - Criminal Record Statement
- LIC 508A (10/09) - Criminal Record Statement - Adoption Facilitator
- LIC 508B (10/09) - Criminal Record Statement - Long-Term Ombudsman Program
- LIC 508D (10/09) - Out-Of-State Disclosure And Criminal Record Statement
- LIC 601 (8/08) - Identification And Emergency Information
- LIC 602 (10/99) - Physician's Report For Community Care Facilities
- LIC 602A (12/04) - 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 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 (10/03) - 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 (1/03) - Personal Rights - Children's Residential Facilities
- LIC 613C (7/05) - Personal Rights Residential Care Facilities for The Elderly
- LIC 621 (4/99) - Client/Resident Personal Property And Valuables
- LIC 622 (3/99) - Centrally Stored Medication And Destruction Record
- 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 625 (8/99) - 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 (8/08) - 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 (8/08) - Child's Preadmission Health History - Parent's Report
- LIC 802 (3/99) - Complaint Report
- LIC 809 (6/04) - 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 856 (2/02) - Complaint Response
- 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 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) - Caregiver Background Check Process
- 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 (4/00) - Register Of Facility Clients/Residents
- 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 (8/05) - Applicant/Licensee Rights
- LIC 9059 (5/99) - Personal Property Procedures
- LIC 9060 (2/00) - Resident Theft And Loss Record
- LIC 9092 (12/99) - 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 (6/04) - Complaint Investigation Report
- LIC 9102 (8/06) - Advisory Notes
- LIC 9106 (1/03) - 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 (12/99) - Facility Compliance Plan
- LIC 9118 (11/03) - Facility Visit Checklist Child Care Centers And Infant Centers
- LIC 9119 (11/03) - Facility Visit Checklist - Group Homes
- LIC 9120 (11/03) - Facility Visit Checklist Adult Residential Facility
- LIC 9121 (11/03) - Facility Visit Checklist Family Child Care
- LIC 9122 (11/03) - Facility Visit Checklist Foster Family Home
- Lic 9122A (11/03) - Facility Visit Checklist Small Family Home
- LIC 9123 (11/03) - Facility Visit Checklist - Residential Care Facility For The Elderly
- LIC 9128 (6/99) - Foster Family Agency Program Statement
- LIC 9139 (2/05) - Renewal Of Continuing Education Course Approval
- LIC 9140 (7/04) - Request For Course Approval
- LIC 9140A (1/06) - Request To Add Or Change Instructor
- LIC 9141 (3/04) - Vendor Application/Renewal
- LIC 9142A (3/06) - Roster Of Participants - For Vendor Use Only - 35/40 Hour Initial Or CEU Courses
- LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC)
- LIC 9149 (2/05) - Family Child Care Home Property Owner/Landlord Consent Form
- LIC 9150 (8/08) - Parent Notification - Additional Children in Care
- LIC 9151 (3/05) - Property Owner/Landlord Notification Family Child Care Home
- LIC 9158 (11/04) - Telecommunications Device Notification
- LIC 9163 (4/08) - Request For Live Scan Service - Community Care Licensing
- LIC 9163B (12/08) - 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 (12/07) - 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 (12/07) - Criminal Record Exemption Transfer Request
- LIC 9194 (9/04) - Live Scan Instructions For State Licensed Facilities
- 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 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 9215 (3/04) - Application For Administrator Re-certification
- LIC 9216 (4/04) - Complaint And Type A Violation Log
- LIC 9217 (3/05) - Pre-Licensing Readiness Guide - Family Child Care Home
- LIC 9218 (2/05) - Application Checklist - Child Care Center
- LIC 9219 (10/06) - Crisis Nursery Monthly Report
- LIC 9219A (10/06) - 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 (3/07) - Child Care Advocate Program
- LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports
- LIC 9225 (4/10) Pre-Placement Questionnaire