Form DHS-5367-ENG "Parent Acknowledgement When Choosing a Legal Non-licensed Provider" - Minnesota

What Is Form DHS-5367-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-5367-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHS-5367-ENG "Parent Acknowledgement When Choosing a Legal Non-licensed Provider" - Minnesota

Download PDF

Fill PDF online

Rate (4.5 / 5) 13 votes
Page background image
DHS-5367-ENG
9-17
MINNESOTA CHILD CARE ASSISTANCE PROGRAMS
Parent Acknowledgment When Choosing a Legal
Nonlicensed Provider
Instructions
Read this form, sign the last page, and return the last page to your Minnesota Child Care Assistance Program (CCAP)
worker. Keep the rest of this form for your records. You must sign and send a page for each Legal Nonlicensed (LNL)
provider you use.
Why did I receive this?
What resources are available to help my legal
nonlicensed provider provide safe care?
You chose a LNL child care provider to care for your
child. We cannot pay for child care from this provider
You and your provider can use the Keeping children safe
until you sign and return the last page of this form. This
in your home (DHS-5192B) checklist to make sure that
form has information that you need to know about using
your provider is meeting basic health and safety
a LNL child care provider.
requirements for caring for young children. You can also
review training materials available in the Health and
What is a legal nonlicensed provider?
Safety Resource List for Parents and Legal Nonlicensed
A LNL provider is a child care provider who is eligible to
Providers (DHS-5192A).
receive payment from CCAP, but is not a licensed child
What if I am using an in-home provider?
care provider.
In-home care is only approved in limited situations. If
Almost everyone who provides child care in Minnesota
you cannot find other care options or your child has a
must be licensed. There are some exceptions. The
special need, ask your worker if in-home care can be
following types of child care do not have to be licensed:
approved. A provider who cares for your child in your
■ Child care provided by a provider who is related* to the
home usually is a LNL provider. If a LNL provider cares
children, and/or child care provided to children from
for your child in your home you are considered the
one family that is not related to the provider.
provider's employer. As the provider's employer you have
(*Related means a grandparent, a sibling, an aunt, or an
legal responsibilities. You will receive the child care
uncle by blood, marriage or court decree.)
assistance payment from the state. You must pay the
■ Child care provided for less than 30 days in any 12
provider the child care payment you receive from the
month period.
state and your copayment, if you have one. If you use an
in-home provider, the county can help you get more
Because CCAP follows licensing law, (Minnesota Statute,
information about your rights and responsibilities as an
section 245A.03, subdivision 2b) the following people
cannot provide care or be paid by CCAP for any child.
employer.
■ A person who applied for a child care license, or who
How do LNL providers get approved to care for
was a child care license holder, who received a license
CCAP children?
denial, conditional license, or sanction that has not
The county must approve all providers before they can
been reversed on appeal.
receive CCAP payments. A LNL provider:
■ A provider or household member who, as a result of
■ Must be at least 18 years of age.
the licensing process, has a disqualification that has not
been set aside.
■ Must complete First Aid and CPR training.
■ Must complete training in Abusive Head Trauma if any
The state does not license LNL providers, but they still
of the children your provider will care for are under
must meet federal, state and local laws that protect
age 5.
children's health and safety. The county or state does not
■ Must complete training in Sudden Unexpected Infant
check LNL providers to make sure they follow these laws.
Death Syndrome if any of the children your provider
This does not mean that the care provided by the LNL
will care for are under age 1.
provider is not safe. It means that you, as a parent, are
responsible for checking the provider you want to use to
make sure it is a good place for your child.
Page 1 of 5
DHS-5367-ENG
9-17
MINNESOTA CHILD CARE ASSISTANCE PROGRAMS
Parent Acknowledgment When Choosing a Legal
Nonlicensed Provider
Instructions
Read this form, sign the last page, and return the last page to your Minnesota Child Care Assistance Program (CCAP)
worker. Keep the rest of this form for your records. You must sign and send a page for each Legal Nonlicensed (LNL)
provider you use.
Why did I receive this?
What resources are available to help my legal
nonlicensed provider provide safe care?
You chose a LNL child care provider to care for your
child. We cannot pay for child care from this provider
You and your provider can use the Keeping children safe
until you sign and return the last page of this form. This
in your home (DHS-5192B) checklist to make sure that
form has information that you need to know about using
your provider is meeting basic health and safety
a LNL child care provider.
requirements for caring for young children. You can also
review training materials available in the Health and
What is a legal nonlicensed provider?
Safety Resource List for Parents and Legal Nonlicensed
A LNL provider is a child care provider who is eligible to
Providers (DHS-5192A).
receive payment from CCAP, but is not a licensed child
What if I am using an in-home provider?
care provider.
In-home care is only approved in limited situations. If
Almost everyone who provides child care in Minnesota
you cannot find other care options or your child has a
must be licensed. There are some exceptions. The
special need, ask your worker if in-home care can be
following types of child care do not have to be licensed:
approved. A provider who cares for your child in your
■ Child care provided by a provider who is related* to the
home usually is a LNL provider. If a LNL provider cares
children, and/or child care provided to children from
for your child in your home you are considered the
one family that is not related to the provider.
provider's employer. As the provider's employer you have
(*Related means a grandparent, a sibling, an aunt, or an
legal responsibilities. You will receive the child care
uncle by blood, marriage or court decree.)
assistance payment from the state. You must pay the
■ Child care provided for less than 30 days in any 12
provider the child care payment you receive from the
month period.
state and your copayment, if you have one. If you use an
in-home provider, the county can help you get more
Because CCAP follows licensing law, (Minnesota Statute,
information about your rights and responsibilities as an
section 245A.03, subdivision 2b) the following people
cannot provide care or be paid by CCAP for any child.
employer.
■ A person who applied for a child care license, or who
How do LNL providers get approved to care for
was a child care license holder, who received a license
CCAP children?
denial, conditional license, or sanction that has not
The county must approve all providers before they can
been reversed on appeal.
receive CCAP payments. A LNL provider:
■ A provider or household member who, as a result of
■ Must be at least 18 years of age.
the licensing process, has a disqualification that has not
been set aside.
■ Must complete First Aid and CPR training.
■ Must complete training in Abusive Head Trauma if any
The state does not license LNL providers, but they still
of the children your provider will care for are under
must meet federal, state and local laws that protect
age 5.
children's health and safety. The county or state does not
■ Must complete training in Sudden Unexpected Infant
check LNL providers to make sure they follow these laws.
Death Syndrome if any of the children your provider
This does not mean that the care provided by the LNL
will care for are under age 1.
provider is not safe. It means that you, as a parent, are
responsible for checking the provider you want to use to
make sure it is a good place for your child.
Page 1 of 5
■ Must complete an additional 8 hours of training in
What information do I have to give my legal
topics listed in the Minnesota Center for Professional
nonlicensed provider?
Development registry for the provider's renewal/
You must give your provider a copy of your child's
reauthorization process. If your provider is not related
immunization record within 30 days of the day your child
to all of your children, this training must be in specific
starts care. You must update this information if your
health and safety topics.
child has more immunizations.
■ Cannot be a member of your family that is receiving
Give your provider emergency information, including
MFIP or CCAP.
telephone numbers where you can be reached when your
■ Cannot share your home or residence.
child is in care.
The LNL provider you chose will get forms to fill out and
What if I have questions about the registration
return to the county. When the provider returns these
forms, the county will check to see if they can approve the
process?
provider to care for CCAP families. The county will do a
If you have questions about the registration process, call
background check on the LNL provider and the members
your CCAP worker.
of their household. If a county knows that a child care
provider is unsafe, the county may deny CCAP payments
for that provider.
We will mail you a notice if we cannot approve your
provider then you can choose a different provider. We
cannot tell you the reason unless the provider says we can
in writing. If we do not approve your provider, you can
appeal the decision.
Page 2 of 5
DHS-5367-ENG 9-17
Clear Form
DHS-5367-ENG
9-17
MINNESOTA CHILD CARE ASSISTANCE PROGRAMS
Legal Nonlicensed Acknowledgment Statement
(Parent completes this form)
Instructions
You must complete and mail this form to your CCAP worker to receive CCAP payment. I understand that by signing
and dating below, I acknowledge reading and understand the following statements.
■ I have read the "Parent Acknowledgment When Choosing a Legal Nonlicensed Provider" section of this form (pages
one and two) and understand the legal nonlicensed (LNL) provider registration process and my rights and
responsibilities when choosing a provider.
■ I know the difference between licensed and LNL providers and know that LNL child care is not checked by the county
or state. I am responsible for my choice of a provider. The county is not responsible for my provider's actions.
■ I know that if the county knows that my provider is not safe, or that the child care is not safe, they may not approve
my provider or may deny CCAP payments for my provider.
■ I know that if I have a provider care for my child in my home, I may be the provider's employer. If I am the employer
I have legal rights and responsibilities. My worker must approve in-home care payments.
■ I understand that my provider and I cannot share the same residence.
■ I understand that my provider must take training, including First Aid and CPR, before authorization is approved.
Additional training is required before CCAP can pay for any child under age 5. An additional 8 hours of training
must be completed by the provider to be reauthorized.
■ My provider and I will review the health and safety information provided by the county.
■ I will give my provider an immunization record for my child within 30 days of the date that child care starts. I will
give my provider any updated immunization information.
■ I know that I cannot receive child care assistance until I have signed and returned this form to the county.
PARENT NAME
CASE NUMBER (if known)
PARENT SIGNATURE
DATE
PROVIDER NAME
PROVIDER STREET ADDRESS
CITY
STATE
ZIP CODE
Parent: Complete, sign and date this form and send it to your CCAP worker.
Page 3 of 5
DHS-5367-ENG 9-17
For accessible formats of this
publication, ask your county worker.
For assistance with additional equal
access to human services, contact your
county's ADA coordinator.
(ADA4 [9-15])
Page 4 of 5
DHS-5367-ENG 9-17
Civil Rights Notice
CB2 (Food/Cash) 10-16
Discrimination is against the law. The Minnesota Department of Human Services (DHS) does not discriminate on the
basis of any of the following:
■ race
■ creed
■ public assistance status
■ disability
■ color
■ religion
■ marital status
■ sex
■ national origin
■ sexual orientation
■ age
■ political beliefs
Civil Rights Complaints
You have the right to file a discrimination complaint if
Contact the OCR directly to file a complaint:
you believe you were treated in a discriminatory way by a
Director
human services agency.
U.S. Department of Health and Human Services'
Office for Civil Rights
Contact DHS directly only if you have a discrimination
200 Independence Avenue SW
complaint:
Room 509F
Civil Rights Coordinator
HHH Building
Minnesota Department of Human Services
Washington, DC 20201
Equal Opportunity and Access Division
800-368-1019 (voice)
P.O. Box 64997
800-537-7697 (TDD)
St. Paul, MN 55164-0997
Complaint Portal:
https://ocrportal.hhs.gov/ocr/
651-431-3040 (voice) or use your preferred relay service
portal/lobby.jsf
Minnesota Department of Human Rights (MDHR)
In accordance with Federal civil rights law and U.S.
In Minnesota, you have the right to file a complaint with
Department of Agriculture (USDA) civil rights
the MDHR if you believe you have been discriminated
regulations and policies, the USDA, its Agencies, offices,
against because of any of the following:
and employees, and institutions participating in or
■ race
■ sex
administering USDA programs are prohibited from
■ color
■ sexual orientation
discriminating based on race, color, national origin, sex,
■ national origin
■ marital status
religious creed, disability, age, political beliefs, or reprisal
■ religion
■ public assistance status
or retaliation for prior civil rights activity in any
■ creed
■ disability
program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means
Contact the MDHR directly to file a complaint:
of communication for program information (e.g. Braille,
Minnesota Department of Human Rights
large print, audiotape, American Sign Language, etc.),
Freeman Building, 625 North Robert Street
should contact the Agency (State or local) where they
St. Paul, MN 55155
applied for benefits. Individuals who are deaf, hard of
651-539-1100 (voice)
hearing or have speech disabilities may contact USDA
800-657-3704 (toll free)
through the Federal Relay Service at 800-877-8339.
711 or 800-627-3529 (MN Relay)
Additionally, program information may be made
651-296-9042 (fax)
available in languages other than English.
Info.MDHR@state.mn.us
(email)
To file a program complaint of discrimination, complete
the
USDA Program Discrimination Complaint
Form,
U.S. Department of Health and Human Services'
(AD-3027) found online at:
www.ascr.usda.gov/
Office for Civil Rights (OCR)
complaint_filing_cust.html, and at any USDA office, or
You have the right to file a complaint with the OCR, a
write a letter addressed to USDA and provide in the
federal agency, if you believe you have been
letter all of the information requested in the form. To
discriminated against because of any of the following:
request a copy of the complaint form, call 866-632-9992.
■ race
■ disability
Submit your completed form or letter to USDA by:
■ color
■ sex
■ national origin
■ religion
(1) mail: U.S. Department of Agriculture
■ age
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Page 5 of 5
DHS-5367-ENG 9-17
Page of 5