Adult Family Homes - Forms

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

  • 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.
Last Revised: January 5, 2015