Residential Care Licensing - Criminal Records Statement
This form is completed by service providers of home shares (including agency supported home shares), mental health facilities, and facilities providing care for persons requiring support due to frailty or cognitive impairment related to aging during the annual review or renewal process. By completing the form, the service provider declares whether, to the best of their knowledge, they as the service provider, any other persons providing residential care in the facility or any other adult (other than residents) residing in the facility, has been charged with or investigated for any criminal or illegal activities.
