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Child Abuse and Neglect Reporting Forms The following forms are for use by government agencies and mandated reporters pertaining to child abuse cases. *To order forms in braille, please contact program directly. Estate Recovery Forms. If you answered "YES" to both Question #1 AND #2, respond to Questions #3 and #4 below, and complete the certification in PART D at the bottom of the form. Statewide Information Management Manual (SIMM) 5310 - A & B. Spanish - NOA will be issued in Spanish. Form # Form Name Instructions Category FACES Warehouse Date; CD-313: . Effective: June 2016 Spanish forms beginning with the letters M through Z . **Due to browser constraints please download forms for full functionality. 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Provide a description of any physical and/or mental condition or functional limitation that has The California Department of Social Services (CDSS) Privacy Notice on Collection covers our practices regarding personal information collected when completing applications and forms (online or hardcopy) for our various programs. Any personal information collected is governed by the requirements of the following authorities and all other laws pertaining to personal information: CDSS collects personal information directly from individuals who volunteer to obtain some of our services. Spanish - California Department of Social Services - CA.gov CDSS forms and publications are available only in Portable Document Format (PDF). Check out how easy it is to complete and eSign documents online using fillable templates and a powerful editor. Certification of Annual Service Fee Exemption. 1952 chevy station wagon; rusty key order of the flaming rose; Venta. 0. 3. Date: _____ Full Medi-Cal benefits were granted pending verification of immigration status. Department of Health Care Services . Other non-English. . Non IV-D Family Violence Questionnaire. 6. Documents (used by county governments) N Forms. Medi-Cal Eligibility Division Translated Forms Back to Forms by Program Medi-Cal Eligibility Division (MCED) forms are listed below in alphabetical order by language. Comments and Help with lic 9108 form california. Search for another form here. Form Adopted for Mandatory Use Judicial Council of California ICWA-020 [Rev. You are here: what is a chalk landing place / shooting in vallejo today / cdss forms spanish. 1 - 25 of 62 Forms. dobitie kreditu tesco mobile. CDSS.docx. 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PUB 389 (8/17) - California Electronic Benefit Transfer (EBT) Card - How To Use Your EBT Card To Make A Purchase. SOC 2302 (Spanish) (4/18) Page 1 of 2 PROGRAMA DE SERVICIOS DE APOYO EN EL HOGAR (IHSS) FORMULARIO DE SOLICITUD DEL PROVEEDOR PARA PAGO POR AUSENCIA REQUISITOS DEL PROVEEDOR: Solamente puede solicitar pago por enfermedad si ha acumulado pago por ausencia por enfermedad. IHSS/WPCS providers those possess queries with creating or accessing their ESP account with entering their control deposit information online can call the IHSS Service Desk during business . PUB 223 (1/04) - So, You Want To Open A Group Home For Children? Name: ICWA-020. 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Application for Child Support Services. Proficient in medicine (prevention), digital health consulting, clinical decision support system (CDSS), clinical data sciences and program management. D Forms. For more information, review the online CDSS Privacy Policy Statement. Narcissistic dimensions impact depressive symptoms and their improvement during inpatient and outpatient treatment across mental disorders and therapeutic methods Within 30 days of a signed collective bargaining agreement, memorandum of understanding (MOU), extension or addendum, a Contract Data Summary Sheet (CDSS) and a copy of the signed agreement is required to be filed with SERB. 584 ENG/SP (8/12 . LIC 624, Unusual Incident/Injury Report. FCCH - Pre-Orientation Registration Information: Wait! Try it now! **Due to browser constraints please download forms for full functionality. If you suspect a case of child abuse in your neighborhood, you should contact your county child welfare agency or local law enforcement agency. On 3/2/2023, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1-Year inspection at the Velasco Family Child Care.Upon arrival, the LPA met with the licensee, Bertha Velasco, who guided the LPA on a tour of the facility. Confidential Referral/Follow-Up Report - PM 161. 1. This form is only for the IHSS program. MC 300 Forms: MC 306 (11/15) - Appointment of Representative; Alt: Spanish (01/08) MC 322 (05/07) - Real and Personal Property - Supplement to Medi-Cal Mail-in Application 7. . or b. eneficiary name: Mailing . You may give this form to your local county office in person or by mail, phone or electronically. (This Publication Is Designed To Be Folded For Use As A Wallet Card. Request accessible version. DFA 285D (8/11) - CalFresh Budget . . The intended user's supervisor must submit a completed form to program staff for processing. Spanish. . Servicios Sociales de California (CDSS), y/o el Condado en donde yo reciba servicios. All Presumptive Eligibility forms for Pregnant Women will now be made available on our provider website for the following form(s): MC 311. To view the minimum operating system requirements to take the online orientation, click the following link: Operation Requirements If you need assistance or have questions please click the Contact Support Link: Contact Support Directions NOTE: Some links on this page are documents in Adobe . PUB 387 (5/09) - California Electronic Benefit Transfer (EBT) Card - The easy, safe, and convenient way to receive your food stamp benefits. This document is for reference purposes only, may not be comprehensive, and is subject to change depending on federal and state statutes and . Document Verification Request (INS Form G-845) and copies of documentation of satisfactory immigration status sent to INS. Every child maltreatment case under s. 39.30 (1) is to be reported and a report made by a child maltreatment case manager or a designee of the child maltreatment case manager with the information or records to . AD 868 (8/14) - Relinquishment Of Indian Child - In/Out of County - Alleged Natural Father In California. Questions and comments are moderated. CDSS forms and publications are available only in Portable Document Format (PDF). Quality Assurance Fee Program. . Tagalog. Here's How - Use Starting June 1, 2020, CW 2166 (11/21) - Multilingual Work Really Pays! To choose an authorized representative to represent the applicant/recipient at a state administrative hearing, complete a separate form, DPA 19 (Authorized Representative). Copies of alien status documents are in the case file. Forms. English. Public Records Act - Government Code section 6250 et seq. 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Tracking Non-California TANF Assistance For Time Limits, CW 2200 (5/22) - Request For Verification, CW 2200LP (6/19) - Request For Verification, CW 2201 (6/09) - Unemployment Insurance Benefits Referral Form, CW 2203 (11/09) - Request For Supplemental Payment By Check Or Direct Deposit, CW 2205 (10/12) - New Rules For CalWORKs Welfare-To-Work Activities, CW 2208 (2/13) - Your Welfare-To-Work 24-Month Time Clock, CW 2209 (12/14) - Immunization Good Cause Request Form, CW 2211 (11/14) - Your CalWORKs Reporting Rules Have Changed, CW 2212 (11/14) - The Rules For Your CalWORKs Case Have Change, CW 2213 (10/15) - Response To Request To Inspect Case Record CalWORKs, CalFresh, TCVAP, And Refugee Programs, CW 2215 (10/20) - California Work Opportunity and Responsibility to Kids (CalWORKs) Important Information for Safety Net And Certain Child-Only Case, CW 2217 (1/15) - CalWORKs Request For Voluntary Repayment, CW 2218 (12/20) - Rights, Responsibilities And Other Important Information For The California Work Opportunity And Responsibility To Kids (CalWORKs) Program (Non-Needy Caretaker Relative With Relative Foster Child) - 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CalFresh Overissuance Notice - Intentional Program Violation (IPV), DFA 377.7F1 (10/00) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV)Only, Final Notice, DFA 377.7G (5/02) - Food Stamp Repayment Notice for an Intentional Program Violation (IPV) Only, DFA 377.10 (6/04) - Food Stamp Notice Of Discontinuance, DPA 13 (7/99) - Request For State Hearing Before The State Department Of Social Services, DPA 19 (6/22) - Appointment OfAuthorized Representative, DPA 315 (7/99) - Withdrawal/Conditional Withdrawals Of Request For Hearing, DPA 421 (7/99) - Notification Of Open Record And Waiver Of Time, DPA 435 (1/18) - County Allegation Of Intentional Program Violation/Statement Of Position (Request For An Administrative Disqualification hearing), DPA 436B (8/18) - County Information Letter, DPA 479 (12/17) - Administrative Disqualification Hearing Waiver - CalWORKs/Food Stamps, EBT 1232 (6/22) - CalFresh Notice Of Action - EBT Account, EBT 2216 (10/22) - EBT Surcharge Free - Direct Deposit Handout, EBT 2259 (1/23) - Report Of Electronic Theft Of Benefits, EBT 2259A (11/21) - EBT Scamming Acknowledgement, EBT 2260 (8/21) - Excessive Card Replacement Warning Letter, EFA 7 (7/21) - The Emergency Food Assistance Program (TEFAP) Certification Of Eligibility, EFA 7A ENG/SP (3/11) - Emergency Food Assistance Program (EFAP) Certification Of Eligibility, EFA 14 (3/23) - The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, EFA 15 (3/23) - Alternate Pick-Up Request Form The Emergency Food Assistance Program (TEFAP) 2023Income Guidelines, FC 2 (11/04) - Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC), FC 2 NM (2/12) - Statement of Facts Supporting Eligibility For AFDC-Extended Foster Care (EFC), FC 31 (8/16) Accreditation Reimbursement Request. 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Person referred to INS to obtain replacement documents. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov including information on the Live Scan application (LIC 9163). Required Form - Substitute with Prior CDSS Approval - Section 23-400.112, Management and Office Procedures - Forms Management Forms in this category are required forms for which modifications or substitutions are permitted with the prior approval of the California Department of Social Services (CDSS). Desired Results Developmental Profile (DRDP) (2015) (PDF; 1MB) Preschool View for use with preschool-age children. Please do not provide personal information that is not requested. [1] [2] [3] Substances range from a variety of plants, spices, foods, and synthetic chemicals. LIC 624, Unusual Incident/Injury Report (PDF; 78.21 KB) LIC 624 (SP), Reporte de incidente inusual o lesin (pdf; 80.58 KB) (CDSS) will begin mailing SY 2021-22 P-EBT cards in November through December 2022. 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Confidential Screening/Billing Report - PM 160 (Refer to EDS Print and Distribution Section, Page 10 of the CMS Catalog) Consent Form - PM 211 (Bilingual) a. ddress (number, street, city, state, ZIP code): Part B: Tell us about the authorized representative: Mailing a. ddress (number, street, city, state, ZIP code): E-mail address: For IHSS Required forms: No accommodation is needed . March 25, 2020] PARENTAL NOTIFICATION OF INDIAN STATUS. For personal information access requests, send an email to CDSS Public Inquiry and Response Unit piar@dss.ca.gov and/or call (916) 651-8848. Alt: Spanish. Kasiya Cdss 2013 Msce Results Extreme Correlation of International Equity Markets - Oct 30 2019 Diseases of the Newborn - Jan 26 2022 Over 9000 English-language entries to medical terminology, with etymology given in Japanese and English. Tips for Using Adobe PDF Files. Third Party Liability Notification. Problems with downloading forms? CD-278-Spanish: Safe Sleep Flyer - Spanish: None: Case Management/Licensing/Resource Development: No: No: 10/21: CS2-ATT Spanish: Parent Response Form: None: Case . For personal information access requests, send an email to CDSS' Public Inquiry and Response Unit piar@dss.ca.gov and/or call (916) 651-8848. AD 880 (1/21) - Declaration Of Birth Parent - Agency And Independent Adoptions Program. chania webcam airport; Servicios de desarrollo Inmobiliario. View Screenshot 2023-04-06 12.02.47 PM.png from SPANISH 2 at United High School. When Spanish or Chinese forms are completed the SW must: Manually enter the referral number, client name(s) and allegation information Import the completed form into CWS/CMS. They will direct you to your program representative. illinois queen of hearts raffle laws Rules of Court, rule 5.481 . Non IV-D Supporting Claim of Family Violence. On 3/14/2022, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1 Year inspection at the Velasco Family Child Care.Family members residing in the home are three adults (licensee, two adult renters who utilize the separate section of the house property-separated by a common wall which is the off-limits television room). Part A: Tell us about you: Applicant. Application for Services Forms. Minimum of 10 characters. Search. Las personas que tienen una cita en una agencia de pasaportes en otro estado/ciudad deben verificar si existen avisos de viaje para el estado/ciudad donde la agencia o centro est ubicado. For tips on how to use PDF files or to download a free copy of Acrobat Reader, Get your free copy . cdss forms spanishaustin, mn jail roster April 9, 2023 . Averige si califica. Supplemental Security Income Self Certification. Korean. www.courts.ca.gov. FDU 113 (7/22) - Civil Rights Annual Training Checklist For CSFP And TEFAP, FS 31 ENG/SP (2/09) - Notice To All Food Stamp Recipients - Important-Please Read - Things You Need To Know, FSP 1 (8/14) - Family Stabilization Program Evaluation Request, FSP 2 (1/21) - Family Stabilization Program Denial Notice, FSP 3 (8/14)Family Stabilization Program Notice of Change in Program Status, GEN 100 (11/20) - Examples Of Verification, GEN 111 (11/20) - Employer Statement Form, GEN 788 (3/22) - Request To Stop My Benefits, GEN 788LP (3/22) - Request To Stop My Benefits, GEN 1179 (5/18) - Complaint of Discrimination, GEN 1388 (9/15) - Language Accessibility Services Complaint Form, GEN 1390 (3/17) - Informing Notice - Regarding An Action Taken On Your Case, HCS 100 (11/21) - Application For Home Care Aide Registration or Renewal, IHSS-E 002 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 003 (1/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances, IHSS-E 004 (4/17) - In-Home Supportive Services Program Notice Of Non-Receipt Of Exemption From Workweek Limits Provider Agreement (APD 006), IHSS-E 005 (1/17) - In-Home Supportive Services Program Notice Of Ineligibility To Request Exemption From, IHSS-E 006 (4/17) - In-Home Supportive Services Program Notice To Provider Of Expiration Of Exemption From Workweek Limits, IHSS-E 007 (4/17) - In-Home Supportive Services (IHSS) Program Notice To Recipient Of Providers Expiration Of Exemption From Workweek Limits, KG 1 (12/11) - Kin-GAP Mutual Agreement For 18 Year Olds, KG 2 (1/11) - Statement Of Facts Supporting Eligibility For Kinship Guardianship Assistance Payment (KinGAP) Program, KG 3 (12/11) - Kin-GAP Mutual Agreement For Nonminor Former Dependents, KG 4 (2/14) - Kinship Guardianship Assistance Payment (Kin-GAP) Program - Nonrecurring Legal Guardianship Expenses Agreement, KG 5 (2/14) - Kinship Guardianship Assistance Payments (Kin-GAP) Program Nonrecurring Legal Guardianship Expenses Form, LIC 00 (8/17) - Conversion to Resource Family: Release of Information, LIC 00A (2/17) - Conversion - Resource Family Application, LIC 01A (9/21) - Resource Family Application, LIC 01C (7/16) - Resource Family Application-Confidential, LIC 03 (8/21) - Resource Family Home Health And Safety Assessment Checklist Document For Agency Use Only, LIC 05A (8/21) - Resource Family Approval Certificate, LIC 12 (8/21) - Resource Family Approval Document Alternative Plan (DAP), LIC 126 (3/21) - Entrance Checklist - Family Child Care Homes, LIC 184A (1/08) - Notification Of Incomplete Foster Family Home Application, LIC 184B (3/22) - Notification Of Incomplete Application - Family Child Care Home, LIC 184C (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers -Pre-30-Day NOIA, LIC 184D (3/22) - Notification Of Incomplete Application (NOIA) Child Care Centers - 30-Day NOIA, LIC 184E (3/22) - Notice Of Incomplete Application (NOIA) Changes To Corporate Status, LIC 192 (7/03) - Notiification Of Initial Application Denial, LIC 198 (1/22) - Child Abuse Central Index Check For County Licensed Facilities, LIC 198B (8/21) - Out-Of-State Child Abuse/Neglect Report Request, LIC 200 (2/11) - Application For A Community Care Facility or Residential Care Facility For The Elderly License, LIC 200A (2/17) - Application For A Child Care Center License, LIC 215 (7/04) - Applicant Information - Facility License, LIC 279 (2/09) - Application For A Family Child Care Home License, LIC 279A (5/17) - License Application And Instructions For Family Child Care Homes, LIC 279B (1/22) - Current Children In Your Home - Application For A Family Child Care Home License, LIC 281A (1/07) - License Application And Instructions For Child Care Centers, LIC 281D (1/17) - Application And Supporting Documentation Checklist Foster Family Agency, LIC 281E (1/17) Application And Supporting documentation Checklist Short - Term Residential Therapeutic Program, LIC 282 (8/08) - Affidavit Regarding Liability Insurance For Family Child Care Home, LIC 283 (4/10) - Foster Family Home Application, LIC 283A (12/07) - Foster Family Home Application Instructions, LIC 300A (01/22) - Removal Confirmation - Exemption Needed, LIC 301E (6/22) - Reference Request - Exemption, LIC 308 (11/02) - Designation of Facility Responsibility, LIC 309 (6/01) - Administrative Organization, LIC 311A (2/22) - Records To Be Maintained At The Facility - Child Care Centers, Infant Centers, School-Age Centers and Child Care Centers For Mildly Ill Children, LIC 311D (2/22) - Forms/Records To Keep In Your Family Child Care Home, LIC 401 (3/01) - Monthly Operating Statement, LIC 401A (3/99) - Supplemental Financial Information, LIC 403A (9/11) - Balance Sheet Supplemental Schedule, LIC 404 (7/99) - Financial Information Release And Verification, LIC 405 (8/01) - Record Of Client's/Resident's Safeguarded Cash Resources, LIC 421A (6/22) - Civil Penalty Assessment (Unlicensed Facility), LIC 421BG (5/19) - Civil Penalty Assessment Caregiver Background Check, LIC 421CC (6/22) - Civil Penalty Assessment Child Care, LIC 421D (CC) (8/22) - Civil Penalty Assessment Death/Serious Injury/Physical Abuse (Child Care), LIC 421FC (7/17) - Civil Penalty Assessment Failure To Correct And Repeat Violations, LIC 421IM (7/17) - Civil Penalty Assessment Immediate $500 And Repeat Violations, LIC 503 (3/99) - Health Screening Report - Facility Personnel, LIC 508 (7/21) - Criminal Record Statement & Out-Of-State Disclosure, LIC 508A (3/11) - Criminal Record Statement - Adoption Facilitator, LIC 508B (3/11) - Criminal Record Statement - Long-Term Ombudsman Program, LIC 508D (8/17) - Out-Of-State Disclosure And Criminal Record Statement, LIC 601 (8/08) - Identification And Emergency Information, LIC 602 (7/22) - Physician's Report For Community Care Facilities, LIC 603 (6/22) - Preplacement Appraisal Information, LIC 605A (7/22) - Release Of Client/Resident Medical Information, LIC 610 (10/03) - Emergency Disaster Plan For Child Care Centers, LIC 610A (01/22) - Emergency Disaster Plan For Family Child Care Homes, LIC 610B (6/02) - Emergency Plan For Foster Family Homes, LIC 610C (10/03) - Emergency Disaster Plan For Children's Residential Facilities (Except Foster Family Homes), LIC 610D (12/21) - Emergency Disaster Plan For Adult Day Programs, Adult Residential Facilities, Residential Care Facilities For The Chronically Ill And Social Rehabilitation Facilities, LIC 610E (3/19) - Emergency Disaster Plan For Residential Care Facilities For The Elderly, LIC 613 (12/02) - Personal Rights Adult Residentail Care Facilities, LIC 613A (8/08) - Personal Rights - Child Care Centers, LIC 613B (6/22) - Personal Rights Childrens Residential Facilities, LIC 613C (1/19) - Personal Rights Residential Care Facilities for The Elderly, LIC 613C-2 (1/19) - Personal Rights Of Residents In Privately Operated Residential Care Facilities For The Elderly, LIC 621 (4/99) - Client/Resident Personal Property And Valuables, LIC 622 (9/19) - Centrally Stored Medication and Destruction Record, LIC 623 (5/01) - Group Planned Activities, LIC 624 (4/99) - Unusual Incident/Injury Report, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home, LIC 624-LE (4/17) - Law Enforcement Contact Report, LIC 625 (11/19) Appraisal/Needs and Services Plan, LIC 627 (9/08) - Consent for Medical Treatment - Child Care Centers Or Family Child Care Homes, LIC 627A (9/08) - Consent To A Medical Examination, LIC 627B (9/08) - Consent For Emergency Medical Treatment - Children's Residential Facilities, LIC 627C (4/00) - Consent For Emergency Medical Treatment - Adult And Elderly Residential Facilities, LIC 700 (10/19) - Identification And Emergency Information Child Care Centers/Family Child Care Homes, LIC 701 (8/08) - Physician's Report - Child Care Centers, LIC 702 (10/19) - Child's Preadmission Health History - Parent/Authorized Representative Report, LIC 860C (12/02) - Facility Review Index Foster Family Homes, LIC 861 (1/03) - Prelicensing In-Home Interview, LIC 973 (4/03) - Documented Alternative Plan - Foster Family Homes (Bedrooms), LIC 974 (4/03) - Documented Alternative Plan - Foster Family Homes (Telephones), LIC 995 (9/08) - Child Care Center - Notification Of Parents' Rights, LIC 995A (8/08) - Family Child Care Home - Notification Of Parents' Rights, LIC 995B (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Removal/Exclusion), LIC 995C (8/08) - Family Child Care Home Addendum To Notification Of Parents' Rights (Regarding Reinstatement), LIC 995D (5/03) - Family Child Care Home Explanation Of Exclusions And Reinstatement, LIC 995E (10/09) - Caregiver Background Check Process, LIC 995F (10/09) - Caregiver Background Check Information, LIC 999 (3/99) - Facility Sketch Floor Plan/Yard Plan, LIC 999A (2/05) - Facility Sketch (Floor Plan) - Family Child Care Home, LIC 9031 (11/99) - Notice Of Temporary Suspension Order Of License, LIC 9040 (10/05) - Child Care Facility Roster, LIC 9054 (3/99) - Local Fire Inspection Authority Information, LIC 9058 (3/22) - Applicant/Licensee Rights, LIC 9108 (3/05) - Statement Acknowledging Requirement To Report Suspected Child Abuse, LIC 9111 (12/99) - Noncompliance Conference Summary, LIC 9121 (7/21) - Facility Visit Checklist Family Child Care, LIC 9148 (9/00) - Earthquake Preparedness Checklist (EPC), LIC 9149 (8/14) - Family Child Care Home Property Owner/Landlord Consent Form, LIC 9150 (8/14) - Parent Notification - Additional Children In Care, LIC 9151 (8/14) - Property Owner/Landlord Notification Family Child Care Home, LIC 9158 (7/22) - Telecommunications Device Notification, LIC 9163 (3/21) - Request Live Scan Service - Community Care, LIC 9166 (2/01) - Consent/Verification for Nebulizer Care, LIC 9182 (11/15) - Criminal Background Clearance Transfer Request, LIC 9188 (11/15) - Criminal Record Exemption Transfer Request, LIC 9211 (9/21) - Request For Inactive Child Care License Status, LIC 9212 (10/05) - Consumer Awareness Information - Family Child Care, LIC 9213 (1/04) - Notice Of Site Visit By A Child Care Licensing Office Representative, LIC 9217 (5/22) - Pre-Licensing Readiness Guide - Family Child Care Home, LIC 9221 (5/22) - Parent Consent For Administration Of Medications And Medication Chart, LIC 9222 (9/05) - Blood Glucose Testing Consent/Verification Child Care Facilities, LIC 9223 (4/17) - Child Care Advocate Program, LIC 9224 (8/08) - Acknowledgement Of Receipt Of Licensing Reports, LIC 9225 (4/10) - Pre-Placement Questionnaire, LIC 9227 (8/20) - Individual Infant Sleeping Plan, LIC 9281 (01/22)- Small Family Home Risk Assessment. 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