Understanding the complexities and nuances of the DHS-3324 form is crucial for anyone involved in the operations of new Community Residential Settings (CFC), Adult Foster Care (AFC), or Family Adult Day Services (FADS) programs within Minnesota. This Supplement to Recommendation Form, issued by the Minnesota Department of Human Services Division of Licensing – Family Systems Unit, plays a vital role in the initial phases of licensing. Its purpose is decidedly focused on ensuring that all Background Studies (BGS) submitted by an agency under a specific facility ID number are duly connected to the pending license for new programs. It's important to highlight that this form should only be submitted after all required BGS for a new license application are completed. This form not only facilitates a smoother licensing process by notifying the Department of Human Services (DHS) about the completion of necessary background checks but also delineates the roles of various individuals involved in the program, including Controlling Individuals (CI), Household Members (HH), staff, and other persons who have undergone background studies. By providing agency and contact information upfront, it ensures a direct line of communication between the agency and the licensing unit, streamlining administrative processes and helping to expedite the final approval of the new license.
| Question | Answer |
|---|---|
| Form Name | Form Dhs 3324 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | mn dhs, mn dhs 3324 license, dhs, mn dhs foster care 3324 |
Minnesota Department of Human Services
Division of Licensing – Family Systems Unit
Supplement to Recommendation Form
**Submit this form with the
The purpose of this form is to notify DHS of BGS’ submitted under your agency facility ID number [40xxx or 42xxx] so that those BGS’ can be connected to the new CFC/AFC/FADS license before it is issued.
(Please do not submit a 3324 for a new license until all BGS’ required for the new license application have been completed.)
Please Check One
CFC
AFC and/or FADS
Study ID # |
Name |
Relationship to Program* |
Date of Birth |
DHS- BGS |
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Last, First, Middle |
CI or HH or Staff or OP |
mm/dd/yyyy |
Completed Date |
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Controlling Individual (CI)- |
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*Key: CI= Controlling Individual |
AGENCY INFORMATION: |
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HH= Household Member |
Licensor Name (Print Clearly):__________________________________ |
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Staff= Employee of Program |
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OP=Other Person Requiring a BGS |
County/Private Agency: _______________________________________ |
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Facility ID Number: 42_______________OR |
40_______________ |
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1.8.2014 |
Telephone Number: ( |
)_____________________________________ |
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