Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

    Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

    If still having trouble viewing or downloading a form, click here.

Effective Date: 
5/2016

Documents

Instructions

Updated: 5/2016

Purpose

  • To assess an applicant's qualifications to provide adult foster care (AFC) and to reassess a provider's qualifications.
  • To verify an AFC home is eligible for enrollment or re-enrollment.
  • To document compliance with Type C personal care home licensure requirements.

Procedure

When to Prepare

The contract manager completes Form 2323 before enrolling the home. After initial contract enrollment, the contract manager completes the form at least once every 12 months from the date of the previous assessment.

Number of Copies

Complete an original of Form 2323.

Prepare a copy if the provider will apply for a Type C personal care home license (four-bed homes only).

Transmittal

File the original in the contract binder.

If the home is licensed, or applying for a license, as a Type C adult foster home (four-bed), mail a copy of the form to the Licensing Section, State Office, E-342.

Form Retention

Keep the original in the contract binder for three years and 90 days after the end of the enrollment period.

Detailed Instructions

Identifying Information— Enter the applicant/provider's name, address and telephone number; enter his contract number (if available), the date of the assessment and the date enrollment/license expires.

Enter the substitute provider's name, address and telephone number.

Initial enrollment/re-enrollment— Check the appropriate box for initial enrollment or re-enrollment.

Initial licensing/renewal— Check the appropriate box if the home is a Type C licensed personal care home.

Provider Qualifications— Indicate in Items 1 through 20 whether the applicant/provider meets the qualifications to provide care.

Home Enrollment Requirements— Check Yes or No to indicate whether the home is in compliance or not in compliance with each of the 30 items. The home must be in compliance with all items before enrollment or re-enrollment, unless a waiver has been granted for AFC. Document in the comments section if a waiver has been granted.

Item 1— Refer to Form 3681-A, Contract Services Contract Application — Addendum A, and refer to the square footage calculation tables to identify the square footage for each AFC bedroom. Staff must measure each bedroom to verify the contractor is in compliance with the square footage requirements.

Household Residents— Enter the names and birth dates of all residents in the household and their relationships to the applicant/provider (family members, private-pay individual, HHSC individual).

Recommendation— Check the appropriate box if the home is or is not recommended.

Signature — The Contract Manager signs and dates the form, prints his/her name and enters the Budgeted Job Number.