Assisted Living Handbook

Forms Table of Contents

For information about forms accessibility, contact DADS at handbookfeedback@dads.state.tx.us

0066Request for Authorized Electronic Monitoring
0066-SRequest for Authorized Electronic Monitoring (Spanish)
0067Consent by Roommate for Authorized Electronic Monitoring
0067-SConsent by Roommate for Authorized Electronic Monitoring (Spanish)
1123Review of Assisted Living Facility Type C
1124Facility Request
1125Resident's Request to Remain in Facility
1126Physician's Assessment
1127Fire Marshal/State Fire Marshal Notification
1129Fire Suppression Authority Notification
2382Assisted Living Facilities Checklist
2383Alzheimer's Certification Checklist
2384Life Safety Code Checklist for Type A & B Facilities - 40 TAC 92.61
2385Life Safety Code Checklist for Small Type A Facilities - 40 TAC 92.61
2386Life Safety Code Checklist for Small Type B Facilities - 40 TAC 92.61
2387Life Safety Code Checklist for Large Type A Facilities - 40 TAC 92.61
2388Life Safety Code Checklist for Large Type B Facilities - 40 TAC 92.61
2389Life Safety Code Checklist for Small Facilities - 40 TAC 92.62
2390Life Safety Code Checklist for Large Facilities - 40 TAC 92.62
2391Life Safety Code Checklist for All Initial Inspections - 40 TAC 92.63
2392Life Safety Code Checklist for Alzheimer's Certification - 40 TAC 92.53
3100Information Regarding Authorized Electronic Monitoring for Assisted Living Facility
3100-SInformation Regarding Authorized Electronic Monitoring for Assisted Living Facility (Spanish)
3613-ASNF, NF, ICF/MR, ALF, ADC and DAHS Provider Investigation Report
3641Alzheimer's Assisted Living Disclosure Statement
3647Assisted Living Disclosure Statement
3707Fire Report for Long Term Care Facilities
3708Amelioration Request
3720Application for State License to Operate a Long-Term Care Facility
3721Application to Certify Long-Term Care Facility for Alzheimer's Disease and Related Disorders or Alzheimer's Assisted Living Facility
4719Fire Drill Report