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Adults

Adult Day Care Centers (ADCC)

New Applicants for Licensure

Initial Application for a State License to Operate an Adult Day Care Center (PDF)

Currently Licensed CDC Providers

Authorization to Release Confidential Information (PDF)
Documentation of Physician's Oral Order for PRN Medication (PDF)
Employee Record (PDF)
First Aid and Cardiopulmonary Resuscitation (CPR) Course Approval (PDF)
Meal Pattern for Adults (PDF)
Medication Administration Record (PDF)
Participant Agreement (PDF)
Participant Assessment (PDF)
Participant Care Plan (PDF)
Participant Record (PDF)
Publication Order Form (PDF)
Record of Emergency Evacuation Drills (PDF)
Record of Initial ADCC Staff Training (PDF)
Record of Staff Training & Education Following Employment (PDF)
Renewal Application for a State License to Operate an Adult Day Care Center (PDF)
Report of Environmental Sanitation Inspection (PDF)
Report of Participant Physical Examination (PDF)
Report of TB Screening (PDF)
Report of Tuberculosis Screening (PDF)
Request for Building Evaluation or Inspection (DOC)
Request for Building Evaluation or Inspection (PDF)
Staff Information Sheet (PDF)
Sworn Disclosure Statement Adult Facilities (PDF)

Adult Protective Services (APS)

APS Report (PDF)
Appendix K (PDF)
Application for Department Approved Provider (PDF)
Assisted Living Eligibility Communication Document (PDF)
Assisted Living Facility Level of Care Worksheet (PDF)
Assurance of Confidentiality (PDF)
Authorization to Act as an Agent on an Adult�s Behalf (PDF)
Certificate of Approval (PDF)
Compliance Form for Department Approved Provider (PDF)
Consent to Exchange Information (PDF)
Consent to Exchange Informationm (Spanish) (PDF)
Interagency Consent to Release Confidential Information for Drug and Alcohol Patients (PDF)
Medicaid Funded Long-term Care Service Authorization (PDF)
Notice of Action Service Programs (PDF)
Report of Guardian for an Incapacitated Person (PDF)
Request for Services Appeal (PDF)
Rights of Adults in Care (PDF)
Service Application (PDF)
Tuberculosis Statement (PDF)
UAI (Uniform Assessment Instrument) Plan of Care (PDF)
UAI (Uniform Assessment Instrument) Private Pay (PDF)

Adult Services (AS)

Appendix K (PDF)
Application for Department Approved Provider (PDF)
Assisted Living Facility Level of Care Worksheet ( (PDF)
Assurance of Confidentiality (PDF)
Authorization to Act as an Agent on an Adult�s Behalf (PDF)
Certificate of Approval (PDF)
Compliance Form for Department Approved Provider (DOC)
Consent to Exchange Information (PDF)
Consent to Exchange Information (Spanish) (PDF)
Eligibility Communication Document (PDF)
Interagency Consent to Release Confidential Information for Drug and Alcohol Patients (PDF)
Medicaid Funded Long-term Care Service Authorization (PDF)
Notice of Action Service Programs (PDF)
Report of Guardian for an Incapacitated Person (PDF)
Rights of Adults in Care (PDF)
Service Application (PDF)
Tuberculosis Statement (PDF)
UAI (PDF)
UAI (Uniform Assessment Instrument) Private Pay (PDF)
UAI (Uniform Assessment Instrument) Virginia (Large Type) (PDF)
UAI (Uniform Assessment Instrument) Virginia Attachment to Short Form (PDF)
Uniform Assessment Instrument (UAI) Plan of Care (PDF)

Assisted Living Facilities (ALF)

New Applicants for Licensure

Initial Application for a State License to Operate an Assisted Living Facility (PDF)

Currently Licensed CDC Providers

Agreement for Mental Health Services (PDF)
Approval for Placement in Special Care Unit (PDF)
Assessment of Serious Cognitive Impairment (PDF)
Authorization for Release of Confidential Information (PDF)
Auxiliary Grant Program Provider/DSS Communication Form (PDF)
Department � Approved Educational Curriculum for Nursing Assistant Geriatric Assistant or Home Health Aide (PDF)
Discharge Notification and Statement (PDF)
Disclosure Statement (PDF)
Disclosure Statement (DOC)
Documentation of Physicians Oral Order for PRN (as needed) Medication (PDF)
Employee Record (PDF)
First Aid and Cardiopulmonary Resuscitation (CPR) Course Approval (PDF)
Individualized Service Plan (DOC)
Individualized Service Plan (PDF)
Medication Administration Record (DOC)
Medication Administration Record (PDF)
Mental Health Progress Report (PDF)
Mental Health Screening Determination Form (PDF)
Non-Availability of Recommended Mental Health Services Form (PDF)
Publication Order Form (PDF)
Record of Initial ALF Staff Training (DOC)
Record of Initial ALF Staff Training (PDF)
Record of On-Site Health Care Oversight (PDF)
Record of On-Site Health Care Oversight (DOC)
Record of Required Fire and Emergency Evacuation Drills (PDF)
Record of Restraint Usage (PDF)
Record of Staff Training and Education Following Employment (PDF)
Renewal Application for a State License to Operate an Assisted Living Facility (PDF)
Report of Environmental Sanitation Inspection (PDF)
Report of Resident Physical Examination (PDF)
Report of TB Screening (PDF)
Report of Tuberculosis Screening (PDF)
Request for Building Evaluation or Inspection (DOC)
Request for Building Evaluation or Inspection (PDF)
Request for First Aid and CPR Course Approval (PDF)
Resident Personal/Social Data (PDF)
Resident Agreement (DOC)
Resident Agreement (PDF)
Review of Appropriateness of Continued Residence in Special Care Unit (PDF)
Rights and Responsibilities of Residents of Assisted Living Facilities (PDF)
Staff Information Sheet (PDF)
Sworn Disclosure Statement Adult Facilities (PDF)
Sworn Statement or Affirmation (PDF)
UAI (Uniform Assessment Instrument) Private Pay (PDF)
UAI (Uniform Assessment Instrument) Private Pay (DOC)

Auxiliary Grants (AG)

AG Certification Form (PDF)
Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Auxiliary Grant Provider Agreement (DOC)
Notification of Change (DOC)
Provider/DSS Communication Form (DOC)
Provider/DSS Communication Form (PDF)
Request for Appeal (PDF)

Benefits

Energy Assistance (Cooling, Crisis, Fuel)

Cooling Assistance (Spanish) (PDF)
Cooling Assistance Application (PDF)
Crisis Assistance (PDF)
Energy Assistance Program Information Sheet (PDF)
Fuel Assistance (PDF)

Food Assistance - SNAP

Appeal to the State Department of Social Services (PDF)
Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Benefit Programs Brochure (PDF)
Social Security Changes (PDF)

Food Assistance - The Emergency Food Assistance Program (TEFAP)

Application for Food Assistance (Web page)

Food Assistance - Women Infants and Children (WIC)

Application for Food Assistance (Web page)

General Relief (GR)

Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Notification of Change (DOC)
Request for Appeal (PDF)

Medicaid

Affidavit of Identity for Medicaid Applicants/Recipients Residing in an Institution (PDF)
Aged Blind Disabled Medicaid Renewal (PDF)
Application for Adult Medical Assistance (PDF)
Application for Adult Medical Assistance (apply online) (Web page)
Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Application for Birth Certificate from VDH (Web page)
Application/Redetermination for Medicaid for SSI Recipients (PDF)
Asset Transfer Undue Hardship Claim (DOC)
Benefit Programs Information Brochure (PDF)
Burial Fund Designation (PDF)
Families & Children Medicaid & FAMIS Plus Renewal (PDF)
Families & Children Medicaid & FAMIS Plus Renewal (Spanish) (PDF)
Health Insurance Application for Children & Pregnant Women (Web page)
Medicaid Funded Long-term Care Service Authorization (PDF)
Notification of Change (DOC)
Plan First Application Form (Web page)
Request for Appeal (PDF)
Title IV-E Foster Care & Medicaid Application/Redetermination (PDF)
Title IV-E Foster Care & Medicaid Initial Evaluation (PDF)

Temporary Assistance for Needy Families (TANF)

Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Benefit Programs Brochure (PDF)
Direct Deposit Enrollment Authorization (PDF)
Request for Appeal (PDF)
Request for Change of Issuance Method (DOC)

Children & Child Support

Adoption

AREVA Family Registration (PDF)
Acknowledgement Form (PDF)
Acknowledgement Form (DOC)
Adoptee Application for Disclosure (PDF)
Adoption Assistance Agreement (PDF)
Adoption Assistance Eligibility Form (PDF)
Adoption Inquiry Form (Web page)
Adoptive Parent Application for Disclosure (DOC)
Adult Birth Sibling Application for Disclosure (DOC)
Application for Adoption Assistance (PDF)
Birth Parent Application for Disclosure (DOC)
Certificate of Service (PDF)
Commissioner's Confidential Report (DOC)
Consent to Adoption (DOC)
Entrustment Agreement for Permanent Surrender of a Child (PDF)
Placement Agreement - Adoptive Home (PDF)
Post-Adoption Contact & Communication Agreement (PDF)
Report of Investigation (DOC)
Virginia Putative Father - Online Registration (Web page)
Virginia Putative Father - Registration (PDF)
Virginia Putative Father - Request to Search Registry (PDF)

Certified Preschools (CP)

Current Providers

Child Placing Agencies (CPA) - Licensed

Background Investigations - Licensed CPA Employees

Background Investigations - Foster & Adoptive Homes

New Applicants for Licensure

Currently Licensed CPA's

Child Care Assistance

Child Care Providers

Child Care ECC Vendor Attendance Sheet (PDF)
Child Care ECC Vendor Attendance Sheet (DOC)
Child Care Vendor Demographics (DOC)
Child Care Vendor Demographics (PDF)
MOA - Licensed Vendors (DOC)
MOA - Licensed Vendors (PDF)
MOA - Religiously Exempt /Voluntarily Registered (DOC)
MOA - Religiously Exempt /Voluntarily Registered (PDF)
MOA - Unlicensed Vendors (DOC)
MOA - Unlicensed Vendors (PDF)
W-9 Form (PDF)
W-9 Form (DOC)

Parents & Guardians

Child Care Service Application & Redetermination (DOC)

Child Care Provider Scholarship Program

Child Day Centers (CDC)

Current CDC Providers

Child Protective Services (CPS)

Children's Residential Facilities (CRF)

CRF - Background Investigations

CRF

Child Support Enforcement (DCSE)

Application for Child Support Services (PDF)
Application for Child Support Services - Spanish (PDF)
Application Addendum - DCSE District Office Addresses (PDF)
Request for Review & Adjustment (PDF)
Direct Deposit Information and Authorization (PDF)
Nondisclosure Affidavit (PDF)
Request for Administrative Appeal (PDF)
Request for Case Closure (PDF)
Request for Change of Name/Address (PDF)
Request for Change of Payee Temporary (PDF)
Statement of Payments Received (PDF)

Family Day Homes (FDH)

Current FDH Providers

Application for Renewal of a State License to Operate a Family Day Home (PDF)
Assistant/Substitute Provider Record (PDF)
Authorization to Apply a Non-Prescription Topical Skin Product (PDF)
Caregiver Reference (PDF)
Checklist for Adult Household Members (PDF)
Child's Record (PDF)
Documentation of Assistant and Substitute Provider Orientation Training (PDF)
Emergency Preparedness and Response Plan (PDF)
Fire Inspection Report (PDF)
Fire Inspection Report (DOC)
General Permission for Regularly Scheduled Trips (PDF)
Individual Health Care/Special Needs (PDF)
Information for Parents (PDF)
Injury Record (PDF)
Liability Insurance Declaration (PDF)
Log of Medication Administration (PDF)
Medication Consent (PDF)
Medication Error Report (PDF)
New Application for a State License to Operate a Family Day Home (PDF)
Permission to Participate in Swimming or Wading Activities (PDF)
Policy for the Administration of Medications (PDF)
Provider Record Checklist (PDF)
Provisions of the Emergency Preparedness and Response Plan (PDF)
Publication Order Form (PDF)
Record of Annual Training (PDF)
Record of Daily Attendance (PDF)
Record of Emergency Response Drills (PDF)
Report of Environmental Sanitation Inspection (PDF)
Report of Tuberculosis Screening Evaluation (PDF)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (DOC)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (PDF)
School Entrance Health Form (Web page)
Special Field Trip Permission (PDF)
Staffing Recommendations for a Child with Special Needs (PDF)
Substitute Provider Time Sheet (PDF)
Sworn Statement or Affirmation for Child Day Programs (PDF)
Weekly Menu (PDF)

Family Day Systems (FDS)/Homes

Current FDS Providers

Annual Operating Statement and Working Budget (PDF)
Asthma Action Plan (PDF)
Balance Sheet (PDF)
First Aid and Cardiopulmonary Resuscitation (CPR) Course Approval (PDF)
Individual Health Care/Asthma (PDF)
Individual Health Care/Special Needs (PDF)
Initial Application for a State License to Operate a Family Day System (PDF)
Liability Insurance Declaration (PDF)
Log of Administration (PDF)
Medication Consent (PDF)
Medication Error Report (PDF)
Plan for Financing the First Year of Operations (PDF)
Publication Order Form (PDF)
Renewal Application Information (PDF)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (DOC)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (PDF)
School Health Entrance Form (Web page)
Staff Information Sheet (PDF)
Sworn Statement or Affirmation for Child Day Programs (PDF)

Family Engagement (FE)

FPM Court Reporting Form (PDF)

Foster Care (FC)

Interstate Compact on Adoption & Medical Assistance (ICAMA)

Interstate/Intercountry Placement of Children (ICPC)

Article VI Blank (PDF)
ICPC Supervision Report (PDF)
Interstate Child's Profile (PDF)
Interstate Compact Placement Request 100A (PDF)
Interstate Compact Report on Child's Placement Status 100B (PDF)

Promoting Safe and Stable Families (PSSF)

Application for Funding

Option 1 Signature Sheet (DOC)
Option 2 Budget Summary (DOC)
Option 3 Community Needs Assessment Guidelines & Funding (DOC)
Report Form (DOC)

Religiously Exempt Child Day Centers (RECDC)

Current Providers

Asthma Action Plan (PDF)
First Aid and Cardiopulmonary Resuscitation (CPR) Course Approval (PDF)
Individual Health Care/Asthma (PDF)
Individual Health Care/Special Needs (PDF)
Log of Administration (PDF)
Medication Consent (PDF)
Medication Error Report (PDF)
Program Decision Not to Administer Medications (PDF)
Program Decision to Administer Medications (PDF)
Public Disclosure Statement (PDF)
Publication Order Form (PDF)
Report of Environmental Sanitation Inspection (PDF)
Request for Building Evaluation or Inspection (DOC)
Request for Building Evaluation or Inspection (PDF)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (DOC)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (PDF)
Required Documentation Checklist (PDF)
School Entrance Health Form (Web page)
Staff Health Report (PDF)
Staff-Child Ratio Information Sheet (PDF)
Statement of Code Compliance (PDF)
Statement of Intent (PDF)
Sworn Statement or Affirmation for Child Day Programs (PDF)

Voluntarily Registered Family Day Homes (VRFDH)

New Applicants & Current Providers

Asthma Action Plan (PDF)
Children's Emergency Medical Authorization (PDF)
Children's Record (PDF)
Emergency Escape Plan (PDF)
First Aid and Cardiopulmonary Resuscitation (CPR) Course Approval (PDF)
Health and Safety Checklist (PDF)
Individual Health Care/Asthma (PDF)
Individual Health Care/Special Needs (PDF)
Injury or Accident Report (PDF)
Liability Insurance Declaration (PDF)
Log of Administration (PDF)
Medication Consent (PDF)
Medication Error Report (PDF)
Permission to Take Child on Trips or Outings (PDF)
Program Decision to Administer Medications (PDF)
Program Decision to Not Administer Prescription Medication (PDF)
Provider Application (PDF)
Publication Order Form (PDF)
Record of Emergency Evacuation Drills (PDF)
Report of Tuberculosis Screening Evaluation (PDF)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (DOC)
Request for Search of the Child Protective Services (CPS) Central Registry - (Effective 11/1/09 - $7.00 Search Fees - New Address) (PDF)
School Entrance Health Form (Web page)
Sworn Statement or Affirmation for Child Day Programs (PDF)

Community Partners

Fatherhood Initiative (FI)

Neighborhood Assistance Program (NAP)

CNF- A ( Business Donations) (DOC)
CNF- B (Health Care Services) (DOC)
CNF-C (Professional Services) (DOC)
CNF-D (Contracting Services) (DOC)
CNF-E (Individual Donations) (DOC)
CNF-H (Pharmaceutical Services) (DOC)
Certification of Donation Value (DOC)
Certification of Proceeds Received (DOC)
Services Contribution Data Sheet - Medical Professionals (DOC)
Services Contribution Data Sheet - Pharmaceutical Services (DOC)
Services Contribution Data Sheet - Professional and Contracting Services (DOC)

Refugee Resettlement - Service Providers with VDSS Contacts

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©Commonwealth of Virginia 2006-2012

Virginia Department of Social Services, 801 E. Main Street, Richmond, VA 23219-2901

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