Forms and Applications
The following forms are used by adult care and family care homes.
Licensure of an Adult Care or Family Care Facility
Licensure of Overnight Respite Services
Registration of Multi-Unit Assisted Housing with Services
Provider Forms
- Template Infection Prevention & Control Policies and Procedures for ACHs and FCHs (DOCX, 723 KB)
- DHSR Request for Emergency Waiver of Regulations For Adult Care Homes & Family Care Homes Tropical Storm Helene (PDF, 119 KB)
- Submission of Training for Penalty Recommendation (PDF, 21 KB)
-
N.C. Licensed Care Facilities Disaster Plan Portal
- DMA 3050 - Adult Care Home Personal Care Services (PCS) Physician Authorization and Plan of Care (PDF, 36 KB)
- Food Service Orientation Manual (PDF, 106 KB)
- Resident Register (PDF, 48 KB)
- Death Reporting Form (PDF, 30 KB)
- Resident Assessment Manual (PDF, 101 KB)
- DMA-9053 - Adult Care Home Hearing Request Form (PDF, 81 KB)
-
DMA-9052 - Adult Care Home Notice of Transfer/Discharge (PDF, 15 KB)
- Medication Administration Audit Tool (Optional Provider Form) (PDF, 113 KB)
- Sliding Scale Insulin Audit Tool (Optional Provider Form) (PDF, 46 KB)
- Coumadin Tracking Tool (Optional Provider Form) (PDF, 134 KB)
- Form DHSR/AC 4640- Guidelines for the Development of Medication Administration
Policies and Procedures (Optional Provider Form)
- Form DHSR/AC 4641- Medication Management Quality Assurance Checklist (Optional
Provider Form)
