Child Residential and Day Treatment Center Forms


The following forms below are offered in PDF format; most forms are fill-in enabled. If a Word version of any form is needed, please contact the Department's Operator Support Hotline at: 1-866-503-3926 or email the BHSL Headquarters Office at: ra-pwarlheadquarters@pa.gov.

 

This is the APPLICATION form that must be completed in order to apply for a license to operate a Child Residential and Day Treatment Center.

Child Residential and Day Treatment Center  - APPLICATION

 

This is the CHILD FUNDS form that may be used in accordance with 55 Pa.Code Section 3800.18.

Child Residential and Day Treatment Center Form - CHILD FUNDS

 

This is the STAFF TRAINING RECORD form that may be used in accordance with 55 Pa.Code Section 3800.58.

Child Residential and Day Treatment Center Form - STAFF TRAINING RECORD

 

This is the FIRE DRILL RECORD form that may be used in accordance with 55 Pa.Code Section 3800.132.

Child Residential and Day Treatment Center Form - FIRE DRILL RECORD

 

This is the CHILD HEALTH AND SAFETY ASSESSMENT form that may be used in accordance with 55 Pa.Code Section 3800.141.

Child Residential and Day Treatment Center Form - CHILD HEALTH AND SAFETY ASSESSMENT

 

This is the CHILD HEALTH EXAMINATION form that may be used in accordance with 55 Pa.Code Section 3800.143.

Child Residential and Day Treatment Center Form - CHILD HEALTH EXAMINATION

 

This is the REPORTABLE INCIDENT form that must be used to report incidents and conditions to DHS in accordance with 55 Pa.Code Section  3800.16. This form is also applicable for human service programs under 55 Pa.Code Chs. 2380, 2390, 2600, 2800, 6400, and 6500.

 Reportable Incident Form - effective October 1, 2016

 

This is the WAIVER form that must be completed and submitted to BHSL for review in order to request a waiver of a regulation.

 Child Residential and Day Treatment Center Form - REQUEST FOR WAIVER OF REGULATION (All Programs)

 

This is the 3800 ENTRANCE CONFERENCE GUIDE to help licensees prepare for inspections.

3800 - Entrance Conference Guide