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Forms

Title Type Posted Date
FBI-1 DHS Fingerprint Verification Form DOC 04/09/2018
NATP Neglect Petition Application Instructions and Related Forms PDF 03/14/2018
DMS-798 - Certified Nursing Assistant (CNA) | Nursing Assistant Registry Exemption/Reciprocity Reque DOC 01/23/2017
DMS-726 - Nursing Homes | Licensure/Renewal/Change of Ownership Form DOC 01/04/2017
DMS-755 - Nursing Assistant Training Cost Reimbursement Claim Form PDF 12/15/2016
DMS-736 - Criminal Record Check | Request for Criminal Record Check for Mandated Employees DOC 09/07/2016
DMS-746 - Nursing Home Administrators | Administrator License Renewal Form DOC 05/02/2016
DMS-7780A1 - Nursing Homes | Daily Staffing Log | Alternate Version | Letter Size PDF 04/12/2016
DMS-7780A2 - Nursing Homes | Daily Staffing Log | Alternate Version | Legal Size PDF 04/12/2016
DHS-703 - Medical Need Determination Form PDF 03/08/2016
Nursing Home Administrators | Reciprocity Licensing Questionnaire DOC 04/14/2015
DMS-762 Completion Guidance Tool PDF 04/13/2015
DCO-9700 - TEFRA Application Form DOC 10/24/2014
DMS-724 - Certified Nursing Assistant (CNA) | Nursing Assistant Training Program Application Form DOC 09/11/2014
OLTC Emergency Preparedness Checklist (Revised March 2014) PDF 03/25/2014
DMS-744 - Adult Day Care, Adult Day Health Care, RCF & PAHI | Application for Licensure DOC 03/13/2013
DMS-803 - Assisted Living Application for Licensure DOC 03/13/2013
DMS-7734 - Nursing Homes | Incident and Accident Next Day Reporting Form DOC 07/30/2012
Suspected Crime Reporting Form under the Elder Justice Act DOC 01/06/2012
APS-0001 - Authorization for Adult Maltreatment Central Registry DOC 09/12/2011
DMS-7790 - Nursing Home Administrators | Application for Nursing Home Administrators DOC 08/23/2011
DMS-7790-Instruct - Nursing Home Administrator Licensure Application Instructions DOC 08/01/2011
ASP-122 - Criminal Record Check | Generic ASP CRC Form for Non-Mandated (RN, LPN, ETC.) Employees DOC
Beneficiary Designation Form DOC
Continuing Education (CEU) Workshop Approval | Attendance Certificate DOC
Continuing Education (CEU) Workshop Approval | Biographical Information DOC
Continuing Education (CEU) Workshop Approval | CEU Review Checklist DOC
Continuing Education (CEU) Workshop Approval | Educational Design DOC
Continuing Education (CEU) Workshop Approval | Evaluation Form DOC
Continuing Education (CEU) Workshop Approval | OLTC Approval Request DOC
Criminal Record Check | FBI Fingerprint Reorder Form DOC
DCO-702 - Notice of Admission, Transfer or Discharge from Facility Form DOC
DHS-9571 - Options Counseling Form DOC
DMS-2602 - TEFRA Waiver | Physician Assessment of Eligibility DOC
DMS-718 - Nursing Homes | Minimum Staffing Reporting Form DOC
DMS-731 - Assisted Living | Incident Reporting Form DOC
DMS-741 - Certified Nursing Assistant (CNA) | Nursing Assistant Trainee Task Performance Record Form DOC
DMS-742 - Assisted Living | Incident Investigation Form DOC
DMS-762 - Nursing Homes | Investigation Report for Resident Abuse, Neglect, Misappropriation of Prop DOC
DMS-7780 - Nursing Homes | Daily Staffing Log DOC
DMS-7799 - Criminal Record Check | LTC Administrator Criminal Record Check and Information Sheet for DOC
DMS-780 - Dementia Diagnosis Substantiation Form DOC
DMS-787 - Mental Illness/Mental Retardation/Developmental Disability - Level I Identification Screen DOC
Residents Bill of Rights Poster Template PDF

Manuals

Title Type Posted Date
ICF/MR Cost Report Forms XLS 07/30/2009
Revised FSR EXCEL 09/30/2004
Daily Midnight Census EXCEL
Participant Ledger Account DOC
PUB-405 - TEFRA Fact Sheet PDF
Beneficiary Receipt Form PDF
Deceased Resident Trust Fund Form DOC

Arkansas Department
of Human Services
(501) 682-1001

TTY: 1-800-285-1131 or dial 711 for Arkansas Relay Service

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