CBRF license class and program statement builder

Wisconsin CBRF | PublicProof Academy working document

Walks through the DHS 83.04 class and size decision and every element DHS 83.06 requires in the program statement.

Business

State or jurisdiction

Prepared on

Owner

Official source saved

Next review

Class and size

Planned capacity and size category (small 5-8, medium 9-20, large 21+)
Can every resident self-evacuate without help? Yes = Class A, No = Class C
Ambulatory / semi-ambulatory / non-ambulatory designation
Client group(s) and why they are compatible

Program statement elements

Licensee name, administrator, and position in charge when both are away
24-hour staffing pattern by shift
Licensed nurse availability
Program goals and services
Limits of services and criteria for who may reside here
Respite care offered? Describe or state none
Program statement given to each person seeking placement before the admission agreement

Use rule: Education and organization only. Record the agency, official source, checked date, cost, proof saved and responsible person for every consequential requirement. Unknown means stop and confirm. Example rows are labeled EXAMPLE and are not your data.