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Forms and Publications

Form Number Title Date Format
APS-0001 Authorization for Adult Maltreatment Central Registry   DOC
ASP-122 Criminal Record Check | Generic ASP CRC Form for Non-Mandated (RN, LPN, etc) Employees (R.12/10) DOC
DCO-702 Notice of Admission, Transfer or DIscharge from Facility Form (R.10/95) DOC
DHS-703 Medical Need Determination Form (R.8/03) PDF
DMS-718 Nursing Homes | Minimum Staffing Reporting Form   DOC
DMS-724 Certified Nursing Assistant (CNA) | Nursing Assistant Training Program Application   DOC
DMS-726 Nursing Homes | Licensure / Renewal / Change of Ownership Form (R.1/13) DOC
DMS-731 Assisted Living | Incident Reporting Form   DOC
DMS-736 Criminal Record Check | Request for Criminal Record Check for Mandated Employees   DOC
DMS-741 Certified Nursing Assistant (CNA) | Nursing Assistant Trainee Task Performance Record Form   DOC
DMS-742 Assisted Living | Incident Investigation Form   DOC
DMS-744 Adult Day Care, Adult Day Health Care, RCF & PAHI | Application for Licensure   DOC
DMS-746 Nursing Home Administrators | Administrator License Renewal Form   DOC
DMS-755 Nursing Assistant Training Cost Reimbursement Claim Form   PDF
DMS-762 Nursing Homes | Investigation Report for Resident Abuse, Neglect, Misappropriation of Property None DOC
DMS-762 Completion Guidance Tool   PDF
DMS-780 Dementia Diagnosis Substantiation Form   DOC
DMS-787 Mental Illness / Mental Retardation / Developmental Disability - Level I Identification Screen   DOC
DMS-798 Certified Nursing Assistant (CNA) | Nursing Assistant Reg. Exemption / Reciprocity Request   DOC
DMS-803 Assisted Living Application for Licensure   DOC
DMS-2602 TEFRA Waiver | Physician Assessment of Eligibility   DOC
DMS-7734 Nursing Homes | Incident and Accident Next Day Reporting Form   DOC
DMS-7780 Nursing Homes | Daily Staffing Log   DOC
DMS-7780A-1 Nursing Homes Daily Staffing Log | Alternate Version | Letter Size   PDF
DMS-7780A-2 Nursing Homes Daily Staffing Log | Alternate Version | Legal Size   PDF
DMS-7790 Nursing Home Administrators | Application for Nursing Home Administrators   DOC
DMS-7790 - Instructions Nursing Home Administrators | Application for Nursing Home Administrators Instructions   DOC
DMS-7799 Criminal Record Check | LTC Administrator Criminal Record Check and Information Sheet (10/07) DOC
DHS-9571 Options Counseling Form   DOC
DCO-9700 TEFRA Application Form (10/12) DOC
  Beneficiary Designation Form   DOC
  Criminal Record Check | FBI Fingerprint Reorder 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 | Educationas Design   DOC
  Continuing Education (CEU) Workshop Approval | Evaluation Form   DOC
  Continuing Education (CEU) Workshop Approval | OLTC Approval Request   DOC
  Nursing Home Administrators | Reciprocity Licensing Questionnaire   DOC
  OLTC Emergency Preparedness Checklist (03/14) PDF
  Suspected Crime Reporting Form Under the Elder Justice Act   DOC

 

Arkansas Department of Human Services
Arkansas Department of Human Services

Arkansas Department
of Human Services
(501) 682-1001

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

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