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Adult Family Homes - Forms

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For questions regarding adult family homes, you may contact the Bureau of Assisted Living, Division of Quality Assurance (attention the Bureau of Assisted Living).

The first two items are fillable PDF forms - select the first field to begin typing. Tab from field to field. You can print this document but you cannot save it.

  • F-62548 (PDF, 17 KB): Assisted Living Facility Request for Waiver, Approval, Variance or Exception

  • F-62500 (PDF, 11 KB): Fire Report form - To report fires in a facility.

  • F-62373 (PDF, 35 KB): Resident Evacuation Assessment

  • Fire Report form DQA F-62500 (Word, 78 KB) - Fillable form with contacts to assist the reporting of fires in a healthcare facility.
  • Fire Watch memorandum DQA 12-013 - Outlines the minimum procedures for when a required sprinkler or fire alarm system is out of service.

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Last Updated: August 21, 2012