AFH Exceptions F-02220 (10/2017)

Adult Family Home Exceptions

A questionnaire for reporting Adult Family Home certification exceptions.
IMPORTANT: Do not provide personally identifiable information. Thanks.

2. Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. Contact Information

Certifying Agency

Agency Contact Last Name

Agency Contact First Name

Phone Number

Email Address

Street Address

Apt/Suite/Office

City

State

Zip

4. Effective Start Date of AFH Certification *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Effective End Date of AFH Certification This question requires a valid date format of MM/DD/YYYY.

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6. Description of Exception Requested *This question is required.

7. Cite the section of the AFH standards that applies. *This question is required.

8. Decision of Certifying Agency

9. Rationale for Decision

10. Date of Decision This question requires a valid date format of MM/DD/YYYY.

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11. Effective End Date of Exception
Please note that any exception approval can be no longer than the one-year certification period. *This question is required. This question requires a valid date format of MM/DD/YYYY.

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12. Summary of Monitoring Plan