MINNESOTA GOVERNMENT DATA PRACTICES ACT …9E2CF57F...9/2016 Page 1 MINNESOTA GOVERNMENT DATA...

9/2016 Page 1

MINNESOTA GOVERNMENT DATA PRACTICES ACT

INVENTORY OF NOT PUBLIC DATA ON INDIVIDUALS

Yellow Medicine CountyResponsible Authority – Rae Ann Keeler-AusYellow Medicine County Family ServicesDirector

Department/DivisionFamily Services – Social Services

Name of Form,Record, File, System,

or Process

Description(Purpose, what it collects, in terms understandable by general public)

Classification Statute Designee

YMCFSC primarily utilizes forms provided by the MN Department ofHuman Services for data collection. Please refer to this website for the

most current MN DHS inventory of forms.https://edocs.state.mn.us/lfserver/Public/DHS-6557-ENG

DHS Notice of social services action Private M.S. 13.46, subd 2Melissa Helgeson,Stacey Steinbach

Social Services Supervisors

Calculation of the parental fee PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey SteinbachSocial Services Supervisors

DHS Notice of privacy practices and completed acknowledgement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Tennessean Warning PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Completed consent for release and exchange of information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Completed death and serious injury reporting form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC CDCS – plan review/approval – fillable and written PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC CDCS – revision request form – fillable and written Private M.S. 13.46, subd 2 Melissa Helgeson,

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YMC CDCS – plan review PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS CDCS – community support plan and budget PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS CDCS – community support plan – Rule 185 compliant – DD PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Intake – social service referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Notification to school to interview child PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Completed data privacy notification PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Alternative Response family assessment worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISNotice of Determination Letter (NOD) Alleged Offender – NO Determ orCPS Needed

PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISNotice of Determination Letter (NOD) – Alleged Offender –Abuse/Neglect OCCURRED CPS NOT



SSISNotice of Determination Letter (NOD) – Alleged Offender –Abuse/Neglect OCCURRED -CPS NEEDED



SSISNotice of Determination letter (NOD) – Alleged Offender – NO Determ –CPS Needed



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SSISNotice of Determination Letter (NOD) – Offending parent – NODetermination – CPS Needed



SSISNotice of Determination letter (NOD) – Offending Parent – NODetermination – CPS NOT Needed



SSISNotice of Determination Letter (NOD) – Offending Parent – NODetermination – CPS NOT Needed



SSISNotice of Determination Letter (NOD) – Offending Parent –Abuse/Neglect OCCURRED – CPS Needed



SSISNotice of Determination Letter (NOD) – Non-Offending Parent –Abuse/Neglect OCCURRED – CPS NOTE Needed



SSIS Voluntary Placement Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Family Safety Plan (alternative response) Private

M.S. 13.46, subd 2 Melissa Helgeson,Stacey Steinbach

Social Services SupervisorsSocial Services Supervisors

MH Screening Notice PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Full Disclosure statement – conc. plng. – parents of kids in FC PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Client/parent safety plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Concurrent planning full disclosure statement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child foster home licensing review Private M.S. 13.46, subd 2 Melissa Helgeson,

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YMC AFC – Incident report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS AFC – relicensing – corporation- applicaiton PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Foster parent evaluation of child placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Clothing Inventory PrivateM.S. 13.46, subd 2 Melissa Helgeson,



FC – Letter of Reference PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Foster home relicensing /alternate year review data PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Family foster care training and skills form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Individual resident placement agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CFC – difficulty of care rating sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


AFC – program abuse prevention plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CFC – incident report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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Initial corp. lic. Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS AFC – relicensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CFC – record of training PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Purchase of service agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Rule 203 lic./relicensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


AFC grievance policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Corp. CFC – relicensing/alt. year checklist (dict. outline) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Completed AFC – home drug and alcohol policy agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC AFC – Initial Licensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC AFC individual abuse prevention plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Foster care correction order (MIGHT BE PUBLIC!) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Adult foster care caregiver training record PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

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DHS Physician’s statement – medication admin assistance PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Family disaster plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Release of info. for CC licensing “background” study PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Permission to administer medication PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Family child care – placement list PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CC – accident report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Completed relicensing materials letter – FCC PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Parent Evaluation PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child care record of training PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Reference for FCC licensing PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Questionnaire for CC applicants PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Request for variance – FCC Private M.S. 13.46, subd 2 Melissa Helgeson,

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YMC Completed FCC – lic. previously licensed in your county letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Variance log PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Criminal background study completion letter – not disq. PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Background study documentation form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Completed unlicensed family child care letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Child care initial licensing checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Completed your right to appeal PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Standard ROI Authorization to Release Rule 25 assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


BSC – 199DHS – 3979

Completed data practices rights advocacy-CD aka Tennessen warning) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Prepetition screening report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Data practices rights advisory (Tennessen warning) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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YMC Close case request letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Case note documentation PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Completed side effects letter – Mental Health PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Clinical Supervision- Mental HealthM.S. 13.46, subd 2 Melissa Helgeson,


Provider Diagnostic Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Closing Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Complete host county notification letter (CADI) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC FSG – prog. Documentation of annual expenditures PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS ISP plan – long form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Provider’s risk management assessment and plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC FSG – application – attachment B PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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YMC FSG – budget of subsidized expenses PrivateM.S. 13.46, subd 2 Melissa Helgeson,


75000-61 Service agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS CSSP – transmittal svs. amendment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Provider Physical exam form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS DD Unit –CSSP & face-to-face tracking sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Adult intake social service referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Completed Tennessen warning PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC Guardianship/conservatorships form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC VA/DD TCM eligibility determination worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Court Completed physician’s cover letter for guardianship PrivateM.S. 13.46, subd 2 Melissa Helgeson,


YMC AP Assessment forms PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Case Closing Summary/Investigative Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

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SSIS VA Investigation PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Completed false findings letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Completed inconclusive findings letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Completed no determination letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Completed substantiated findings letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


ASQ – NA ASQ -3 2 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,


ASQ – NA ASQ -3 4 mo. questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,










ASQ – NA ASQ -3 14 mo. questionnaire Private M.S. 13.46, subd 2 Melissa Helgeson,

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ASQ – NA ASQ-3 20 mo. Questionnaire PrivateM.S. 13.46, subd 2 Melissa Helgeson,


















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CH-NA Children’s Mental Health Referral Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Court-NA Notice child returned to care parent or legal custodian PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 0033 Appeal to state agency PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS - 0139 Agreement Between Foster Parents and Placement AgencyM.S. 13.46, subd 2 Melissa Helgeson,


DHS –0250

MN DHS Div. of Licensing Family Systems Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 0312Adoption Placement agreement for child under state guardianship(2010)



DHS – 0644 Home Safety Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 0968 Adoptive Applicant Registration State Adoption Exchange PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 1542D Interstate Compact – Placement of Children Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 1715 Family day care admission and arrangements PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 13


DHS – 1995 Physician’s Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 2140 Application for Social Services PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 2424 Request for Fire Inspection PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 2720 Floor and Escape Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 2780 Client Placement Authorization - CCDTF PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 2794 Rule 25 Assessment and Placement Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 0188 Report to court petition for adoption PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 0178 Report of Adoptive Placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3067 DD Screening Document PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3070 Service Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3141 Variance Request PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3152 Completed TCM data transmittal Private M.S. 13.46, subd 2 Melissa Helgeson,

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DHS – 3218 Emergency relative FC license application PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3235 Background and Health History PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3243 CEP Intake form – VA maltreatment report – disclosure PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3324 Div. of Lic. Family Systems Unit Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3428A MN LTCC Services Assessment form: SW section PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3478Title IV-E Foster Care Supplement of the Health Care ProgramsApplication



DHS - 3614 CAC Application/Reassessment Support Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3848 Related Conditions Checklist (DD) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS - 4268Association of Administrators of the Interstate Compact on thePlacement of Children



DHS – 4007 County of Financial Responsibility PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4147ACase Manager’s Guide to Determining ICF/DD Level of Care for ICF/DDand DD Waiver Services



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DHS – 4258A MN Adoption and Foster Care Application – Home Study PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258B MN Adoption and Foster Care Individual Fact Sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258C Agency Home Study Checklist for Eligibility PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258D Home Study Assessment (fillable) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258E Home Study Assessment Update (fillable) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258F Family Disaster Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4266 Interstate Compact – placement – children – request PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4267 Interstate Compact – Placement – children – report placement status PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4369 Notice of Social Service Action PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4689A Screening Deletion Request – DD PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Monthly Crib Inspection Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 5017 Summary of Diagnostic Findings Related to PASARR Mental Illness PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

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DHS – 5178 Emergency Relative Placement – FC Referral form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 5204 Rule 25 Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 5225 Data Practices Agreement (ICWA) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 5227 ICWA Notice to Tribe of Services to an Indian Child PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS - 7216 Physician Directive for alternative infant sleep position PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 5883 Substantiated perpetrator reporting form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 6123 State Medical Review Team Referral for Disability Determination PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 6124 Authorization to Disclose Protected Health Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 6125 Adult Disability Worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 6249 LOCUS Recording Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Consent/Authorization for release of information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS –NA Functional Assessment (AKA mental health scale) Private M.S. 13.46, subd 2 Melissa Helgeson,

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DHS – NA Immediate risk of harm determination worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – NA Individual abuse prevention plan – IAPP PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – NA Req. – reconsideration of disqualification form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – NA Rule 203 AFC lic. checklist consolidated stds. sites PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MED – NA SNBC – PIN Health Risk Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MDH Certificate of adoption PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MDH Child Care Immunization Record PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MDH MN Birth Record Appl. Certified Copy PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MN-SFM Owner Permission – State Fire Marshall Inspection PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MNTS MN Telephone Svc. Discount Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Ombudsman Death Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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Ombudsman Death – Serious Injury fax cover PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Ombudsman Serious Injury Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


PSC Pediatric Systems Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Salvation Army Agency Referral Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS AP – VA Investigation PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CH MH – advisory and notice of rights – SED child in vol. placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISCH MH – referral – review – vol. placement – DD or emotionallydisturbed children (SED)



SSIS CP – case summary /closing PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – checklist for youth 16+ (in care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report 90 – day TBR review – child 16 and over PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report 90- day TPR review – child under 16 PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report – child at home PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 19


SSIS CP – court report – child at home ICWA PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report – child out of home PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report – child out of home and over 16 PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report – child out of home and over 16 - ICWA PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISCP – court report – child out-of-home and under 16



SSIS CP – court report – child out-of-home and under 16 – ICWA PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – court report – informal review order PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISCP – court report – informal review – vol. placement – DD/EmotionallyDisturbed



SSISCP – disposition of child protection report – notice to mandatedreporters



SSIS CP – Family Safety Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS CP – Request for Police Records PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS DD – CSSP – individual service plan (long form) Private M.S. 13.46, subd 2 Melissa Helgeson,

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DHS DD –CSSP Individual service plan – Form B (short form) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Intake – CP Case Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Intake – CP screen out maltreatment/mandated reporter – screener PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Intake – CP screen out maltreatment/vol. reporter screener PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISIV-E – Title IV-E Foster Care 6 month continuing reimbursementchecklist



YMC MH – Commitment Report 1: 60-90 day treatment report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS MH – crisis plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS MH – functional assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MH – individual community support plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS MH – prepetition screening report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MH SOC1 – court report : stayed order of commitment report (90 day) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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MH SOC3 – court report: request extension of stayed order ofcommitment report



MH SOC4 – court report: request revocation of stayed order ofcommitment report



MH SOC5 – court report : extension of stayed order of commitmentreport



Placement Team – child –respite care request PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Social Services Form IV-E Eligibility Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Social Services Form Relative Search Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adoption Delegation of Powers by Parent PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adult Foster Care AFC Case Notes PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adult Foster Care Incident Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adult Foster Care Individual Abuse Prevention Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adult Foster Care Individual Resident Placement Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adult Foster Care Training Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 22


Adult Foster Care Fire Drill Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Adult Foster Care Grievance Policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Consent for a Background Check Child Foster Care/Adoption PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Clothing Inventory and Record PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Data Privacy and Confidentiality PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Discipline Policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Emergency Procedures PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Initial Foster Care Licensure Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Mandated Reporting Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Medical Assistance Mileage Reimbursement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Monthly Visits for 6 Months after Licensure PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Placement Record Private M.S. 13.46, subd 2 Melissa Helgeson,

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Child Foster Care Reference Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Training Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Foster Care Variance Request PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Licensing (General) Chemical Use Policy PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Licensing (General) Complaint Log PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Licensing (General) Correction Order PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Placement Clothing Allowance Request PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Placement Out of Home Placement Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Respite Care Respite Consent for Background Check PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Supervised Visitation Report of Suspected Abuse or Neglect PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Background Consent Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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Child Care Licensing Reference Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Your Privacy Rights PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Provider’s Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Child Abuse/Neglect Reporting (Mandated Reporting) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Day Care Licensing Home Study PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Provider Policy Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Serious Injury Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Log of Monthly Fire Drills PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Training Logs PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Record of Background/Chemical Use Policy/training requirements PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Variance application PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Request for Reconsideration of a Disqualification PrivateM.S. 13.46, subd 2 Melissa Helgeson,

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9/2016 Page 25


Child Care Licensing Variance due to Well Water Test PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Child Care Licensing Emergency Phone Numbers Records PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Child Care Assistance Program Application Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 3550 MCCAP Application PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3551 Do you need help paying for child care? Brochure PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3979 Notice of Privacy Practices PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3163B Referral to Support and Collections PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 2338 Cooperation with Child Support Enforcement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP CCAP Redetermination Cover Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5274 CCAP Redetermination Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 2402 Change Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5190 CCAP Licensed Provider Registration Acknowledgement Private M.S. 13.46, subd 2 Melissa Helgeson,

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CCAP DHS – 5191 CCAP Licensed Exempt Provider Registration and Acknowledgement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS - 5192 CCAP Legal Nonlicensed Provider Registration and Acknowledgement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 4079 Child Care Provider Responsibilities and Rights PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3985 Notice of Privacy Practices for Child Care Providers PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3552 Direct Deposit for Minnesota Child Care Assistance Program PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS - 5318 CCAP Financial Tracking Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5192AHealth and Safety Resource List for Parents and Legal NonlicensedProviders



CCAP DHS – 5193 CCAP Authorization for Release of Background Study PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 6419CCAP Training Requirements for Legal Nonlicensed Family Providers –Questions and Answers



CCAP DHS – 5367CCAP Parent Acknowledgment When Choosing a Legal NonlicensedProvider



CCAP DHS – 4795 CCAP Quality Differential Rate Request Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


9/2016 Page 27

CCAP W-9 PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 4018 Important Information for Child Care Providers PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5242 Child Care Assistance Notice of Decision PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5260 CCAP Child Care Provider Guide PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3131A CCAP Provider Notice of Intentional Program Violation – Waiver of ADH PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS - 5523 Child Care Assistance Billing Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Service Authorization Provider PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3429A CCAP Disqualification Consent Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 4003 Child Care Status Transmittal Update to Child Support PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 6475 CCAP Parent Request for In-home Child Care PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3627Important Information about Your Request for a Child Support GoodCause Exemption



CCAP DHS – 3628 Denial of Good Cause Claim PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 28


CCAP DHS – 3629 Notice of Good Cause Approval PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3630 Notice of Good Cause Redetermination PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3633 Notice of Good Cause Approval for Redetermination PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3631 Notice to End Good Cause PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3429 Disqualification Consent Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5223D Combined Application – Child Care Addendum PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS - 2120 Household Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 2646 Financial Aid Information Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 2919A Verification Request Form A PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 2919B Verification Request Form B PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 3336 Self-employment Report Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 4794 CCAP Program Change Report Form Private M.S. 13.46, subd 2 Melissa Helgeson,

9/2016 Page 29


CCAP DHS – 5223 Combined Application Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5223C Combined Application Form Addendum PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 4194 CCAP Special Needs Rate Variance Request/Parent & Provider PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 4195 CCAP Special Needs Rate Variance Request – County Recommendation PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5588 Notice of Decision – Denial PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5588A Notice of Decision – Termination PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 5671 Basic Sliding Fee Monthly Waiting List PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 6035A Proof of Residence PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 6413 Co-payment Schedule PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP DHS – 6441B Standard Maximum Rates PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 6443 Maximum Registration Fees PrivateM.S. 13.46, subd 2 Melissa Helgeson,


9/2016 Page 30

DHS – 0033 Appeal Request to State PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Service Authorization Family PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Education/Employment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Employment Services Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Redetermination Cover Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAPEligibility Approval –Opening/Closing/Re-Opened/Redetermination/Denial/Co-pay Change



CCAPSpecial Letter for Information Request –Identity/DOB/Relationship/Citizen Status/Residence/Activity/Financial



CCAP CCAP Memo PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Notice of Intentional Program Violation PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Request for ADH Hearing PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Notification of Overpayment to Claims Department PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Client Repayment Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 31


CCAP Client Notice of Recoupment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Client Notice of Repayment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CCAP Client Notice of Revenue Recapture PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Functional Assessment PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH CASSI PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH SDQ PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Individual Family Community Support Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Respite /Foster Care Child Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMHChecklist for Guide Case Manager Activities in Qualifying a Child forChildren’s Mental Health Case Management Services



CMH Client Rights and Responsibilities PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Notice of Privacy Practices PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Authorization to Release Information List Private M.S. 13.46, subd 2 Melissa Helgeson,

9/2016 Page 32


CMH Clinical Supervision of Case Manager PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Prime West TCM Service Authorization Request Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Consent for Release of Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS-2140 Application for Social Services PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH CMH Determine Eligible Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Closing Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Diagnostic Referral Letter PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Notification of Availability of Children’s Mental Health Services PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS-1776 Voluntary Out of Home Placement Agreement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Pre-placement Review Team Meeting PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Agency Notification of Placement PrivateM.S. 13.46, subd 2 Melissa Helgeson,


9/2016 Page 33

CMH Notice to Parents of Financial Responsibility (placement) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Difficulty of Care Assessment Schedule PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS-6126 Children’s Disability Worksheet (SMRT) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS -6123 SMRT Referral for Disability Determination PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH SMRT Request for Child Medical Examination PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH CTSS Referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Intensive In-home Counseling Referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Family Group Decision Making Referral PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Delegation of Powers by Parent PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH CSIS Vendored Service Voucher PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Signs of Safety Assessment and Planning Form PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Signs of Safety Harm and Danger Statement PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 34


CMH Closing Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH Relative Search PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH PSOP Case Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH FA Response Summary PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS-6349 MHCP Request for Disability Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS-6124 SMRT Authorization to Release Protected Health Information PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – Daycare Admissions and Arrangements PrivateM.S. 13.46, subd 2 Melissa Helgeson,


MDH Immunization PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co.Daycare

Accident Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS -Daycare Insurance Notice PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS -7218 Parental Consent for Swaddling an Infant PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Drug and Alcohol Policy (Daycare, Adult & Child Foster Care, FADS) Private M.S. 13.46, subd 2 Melissa Helgeson,

9/2016 Page 35



Fact Sheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Fire MarshalFire Marshal Inspection Results (Daycare, Adult & Child Foster Care,FADS)



Fire MarshalFire Marshal Inspection Request (Daycare, Adult & Child Foster Care,FADS)



DHS – 2720 Floor and Escape Plan PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Furnace Inspection (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Client Grievance Policy (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Home Safety Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,



Permission to AdministerM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 1995 Physician’s Report PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Client Program Policies (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Program Plan (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


9/2016 Page 36

Yellow Medicine Co.,DHS

Provide Agreement (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Training Record (Daycare, Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Video Worksheet - Daycare PrivateM.S. 13.46, subd 2 Melissa Helgeson,


State Application (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Initial License Checklist (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Relicense Checklist (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Relicense Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Negative Action Parent Letter (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSISNegative Action Recommendation Letter (Daycare, Adult & Child FosterCare, FADS)



Yellow Medicine Co.,SSIS

Negative Action Provider Letter (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Correction Order (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Correction Order Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 37


Yellow Medicine Co. Relicensing Follow-up Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co.Investigation Form or Information (Daycare, Adult & Child Foster Care,FADS)



DHSNegative Action Determination (Daycare, Adult & Child Foster Care,FADS)



Yellow Medicine Co. Background Study Form (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Background Study More Time Needed (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,



Clearance Letter (Daycare, Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Negative Action Reconsideration (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Negative Action Appeal (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Client Incident Reports (Child & Adult Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Parent Evaluations and Cover Letter (Daycare) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Client Evaluations and Cover Letter (Child & Adult Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. License Recommendation (Daycare) Private M.S. 13.46, subd 2 Melissa Helgeson,

9/2016 Page 38


DHS - 0644 Home Safety Checklist Addendum (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Client Discipline Policy (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258D Home Study (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258E Home Study Update (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258B Individual Fact Sheet (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS Statement of Intended Use (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Substitute Care Plan (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Provider History Update (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. List of Current Placements (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Insurance Verification (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS – 4258C Home Study Checklist PrivateM.S. 13.46, subd 2 Melissa Helgeson,


9/2016 Page 39

Yellow Medicine Co. Evaluation by Provider (Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Client Chemical Use Signature Policy (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co.,Client

Placement Forms (Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co.,Client

Discharge Forms (Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Annual Contact (Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Dual License Initial Checklist (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Dual Relicense Checklist (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,



Crisis 5th Bed Forms (Adult) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Change of Premise Checklist (Daycare, Adult & Child Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS License Checklist (Adult & Child Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Employee Quarterly Report (Child and Adult Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. List of Current Residents (Child & Adult Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,

Stacey Steinbach

9/2016 Page 40


Yellow Medicine Co. Residents for Last 5 years (Child & Adult Foster Care) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS, Client Program Abuse Prevention Plan (Child & Adult Foster Care, FADS) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Individual Community Support Plan (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Functional Assessment (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co.Request for Information Letter (Adult Mental Health, Special NeedsBasic Care - SNBC)



Yellow Medicine Co.,Program

Referral to a Service (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Service Closing Letter (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Crisis Plan (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Medication Side Effects Referral (Adult Mental Health) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


SSIS Diagnostic Assessment Referral (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Yellow Medicine Co. Client Information Sheet (Adult Mental Health, SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


Provider Diagnostic Assessment, psychological (Adult Mental Health, SNBC) Private M.S. 13.46, subd 2 Melissa Helgeson,

9/2016 Page 41


PrimeWest Care Plan (SNBC) PrivateM.S. 13.46, subd 2 Melissa Helgeson,


DHS - 2925 Long Term Care Consultation Community Support PrivateM.S. 13.46, subd 2 Melissa Helgeson,


CMH DHS-6126 SMRT Children’s Disability Worksheet PrivateM.S. 13.46, subd 2 Melissa Helgeson,


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