Is more than one (1) Member receiving services within this Shared Living arrangement? Yes_____ No_____ If yes, is there evidence to support that DHHS has approved this arrangement? Yes_____ No_____ Evidence of DHHS approval must be kept in each Member record. Only one (1) member may receive services in any one Shared Living arrangement at the same time, unless a relationship existed prior to the service arrangement and the arrangement is approved by DHHS. In such cases, no more than two (2) members may be served in any Shared Living arrangement concurrently. Revised September 2016/BC/PCU Appendix C: Shared Living Background Check Statement Shared Living Background Check Statement Date: _________________ Name of Contractor: ______________________________ Date of Contract: _____________ Name of Member living in the Home: _____________________________________________ Complete the following to include date checks were completed on everyone 18 years or older. Name of all Individuals Living in the Home and Date of Initial Date of Criminal Individuals who Lives in Provides Date of Adult Criminal Background Provide the Transportation Date Of Protective Background Check following Transportation. Home to the Member Birth Check Initial Check
Is more than one (1) Member receiving services within this Shared Living arrangement? Yes_____ No_____ If yes, is there evidence to support that DHHS has approved this arrangement? Yes_____ No_____ Evidence of DHHS approval must be kept in each Member record. Only one (1) member may receive services in any one Shared Living arrangement at the same time, unless a relationship existed prior to the service arrangement and the arrangement is approved by DHHS. In such cases, no more than two (2) members may be served in any Shared Living arrangement concurrently. Revised September 2016/BC/PCU Appendix C: Shared Living Background Check Statement Shared Living Background Check Statement Date: _________________ Name of Contractor: ______________________________ Date of Contract: _____________ Name of Member living in the Home: _____________________________________________ Complete the following to include date checks were completed on everyone 18 years or older. Name of all Individuals Living in the Home and Individuals who Provide Transportation. Lives in the Home Provides Transportation to the Member Date Of Birth Date of Adult Protective Check Date of Initial Criminal Background Date of Criminal Background Check following Initial Check