Blank Oregon Dhs Child Care Provider Form Open Editor Now

Blank Oregon Dhs Child Care Provider Form

The Oregon DHS Child Care Provider form is a crucial document that assists in determining whether a child care provider needs to be licensed by the Office of Child Care (OCC). This form is essential for both licensed and license-exempt providers, ensuring compliance with state regulations. By completing this form, providers can clarify their status and fulfill necessary requirements to offer child care services in Oregon.

Open Editor Now
Navigation

The Oregon Department of Human Services (ODHS) Child Care Provider form is a crucial document for both child care providers and parents seeking assistance with child care services. This form is designed to determine whether a provider needs to be licensed with the Office of Child Care (OCC) or if they qualify for license-exempt status. It includes specific instructions for providers, depending on their relationship to the children in their care. For instance, non-relative providers must complete certain training courses, including health and safety training, and must also conduct lead testing on their water supply. The form requires providers to provide detailed information about their qualifications and the environment in which they will care for children. Additionally, background checks are mandated for both the provider and any household members aged 16 or older. Once completed, the form must be submitted within a specified timeframe to ensure timely processing. Understanding the requirements and steps outlined in this form is essential for compliance and to facilitate child care assistance payments from ODHS.

Form Example

Page I of VI DELC 7494d (07/2023) recycle prior versions
Child Care Provider Listing
Form Instructions
Parent: Please immediately give this form to your
child care provider to complete.
Provider: For help completing this form contact your local Child Care Resource and Referral
(CCR&R) office. To find an office near you call: CCR&R Centralized Coordination at 1-800-342-6712
(toll-free)
Licensing and license-exempt status
» If you are currently licensed with the Child Care Licensing Division (CCLD), go to page 4 for instructions.
» If you are not licensed with CCLD and:
• You are not related to all children in care.
» You are likely providing license-exempt non-relative care. Go to page 2 of the instructions.
• You are a grandparent, great-grandparent, aunt, uncle (does not include great-aunt and great-
uncle) or a sibling (siblings must not live in the same home as the child needing care). Relationships
must be by blood, adoption or marriage. This includes blood relationships established before the
child was adopted. Relationships by marriage continue even if a spouse dies.
» You are likely providing license-exempt relative care. Go to page 3 of the instructions.
Are you required to be licensed with the Child Care Licensing Division?
Child care providers are legally required to be licensed with CCLD unless they are exempt
from licensing (license-exempt).
How to determine your license or license-exempt status
Please select all the statements below that apply to you.
If you provide care in a home, you are exempt from licensing if:
You are providing c
are in the home of the child but do not live with the child.
All the children you care for, not including your own children, are from the same family.
You are caring for three or fewer children, not including your own children, at any one time.
You are related to the children in care by blood, marriage or adoption.
If you provide care in a facility, you are exempt from licensing if:
You do not care for children more than 70 days in a year.
A school district, political subdivision of the state or a governmental agency operates the program.
You are operating a pre-school recorded program.
If you meet one of the above exemptions, CCLD may not require licensing of your home or facility.
To see if you need to be licensed, call CCLD at 503-947-1400 or 1-800-556-6616.
The Department of Early Learning and Care (DELC) uses this information to help determine if you
need to be licensed with CCLD. This is an informational tool only.
Page II of VI DELC 7494d (07/2023) recycle prior versions
Instructions for license-exempt non-relative care
Training
If CCLD does not require you to have a license and you are not related to all children in care, you will
need to complete the following before submitting a completed Child Care Provider Listing Form:
• Introduction to Child Care Health & Safety training (take online)
» Online training: www.oregon.gov/delc/programs/pages/erdc-training.aspx
• Recognizing and Reporting Child Abuse and Neglect training
» In-person training: Contact your local CCR&R at 1-800-342-6712 or
» Online training: www.oregon.gov/delc/programs/pages/erdc-training.aspx
• Infant/Toddler CPR/First Aid training
For training locations, contact your local CCR&R at 1-800-342-6712. If you are unable to take the
Infant/Toddler CPR/First Aid class before turning in this form, you may be eligible for a short-term
waiver. Contact your local CCR&R for more information about the waiver process. For a list of
CCR&R offices, go to www.oregonccrr.org, call 1-800-342-6712 or call 211 Info. Strictly online CPR
training is not acceptable.
Attach a copy of your “Infant/Toddler CPR/First Aid Card” to this form if you took this training from
another agency besides the local CCR&R.
Note: The director and staff members who work with children in care and volunteers who may have
unsupervised access to children are also required to take the above trainings.
Water testing requirements
License-exempt child care providers who are not related to all children in care must test their water
supply for lead in any plumbing fixture used for drinking, preparing food or formula before submitting
their Child Care Provider Listing Form. Submit a copy of the water sample results with your listing form.
Please note: Lead testing is not needed if you provide care in the child’s home and you live somewhere
else.
CCLD can reimburse you for the cost of lead testing. For a reimbursement form and information on
how to test your water, visit www.oregon.gov/delc/providers/pages/lead-testing.aspx.
For information on preventing exposure to lead, contact CCLD at 503-947-5908 or visit their website at
www.oregon.gov/delc/providers/pages/lead-testing.aspx.
After completing the above trainings and water testing:
• Complete and sign the attached Child Care Provider Listing Form using black or blue ink.
• Mail the form within 30 days from the date issued in the “ODHS branch use only” section. Mail to
the Direct Pay Unit (DPU) at P.O. Box 14850, Salem, OR 97309-0850, fax to 503-378-5953 or email
[email protected] (PDF only)
• Contact DPU for questions at: 1-800-699-9074 (toll-free) or 503-378-5500 (Salem area).
• Complete the Central Background Registry (CBR) application to start the process for background
checks. To get the CBR application go to: www.oregon.gov/DELC or call CCLD at 1-800-556-6616.
For more information see page 9. You can either download, print, and mail the application or fill
out the online application and submit it electronically to CCLD.
Page III of VI DELC 7494d (07/2023) recycle prior versions
• CCLD must conduct a home/facility visit before approving you as a child care provider. This also
includes care provided in the child’s home. After DELC reviews your provider listing form and verifies
you have completed trainings, an CCLD staff person will contact you to schedule a visit where child
care will be provided. The CCLD staff person will check to make sure the home/facility meets all
health and safety requirements as required by DELC. The staff person can talk with you about
concerns or questions you have and share resources or training material.
» Before this visit, you may review the CCLD's Health and Safety Checklist. Find the checklist at
www.oregon.gov/DHS/ASSISTANCE/CHILD-CARE/Documents/Regulated-Subsidy-Checklist-
RS-404.pdf.
Please also see section “Additional information for both relative and non-relative license-exempt
providers” below.
Instructions for license-exempt relative care
Note: A relative is a grandparent, great-grandparent, aunt, uncle (does not include great-aunt and
great-uncle) or a sibling (not living in the home of the child).
Training
If you are not required to be licensed with CCLD and you are related to the child or children in care, you
will need to complete the following before submitting a completed Child Care Provider Listing Form:
• Introduction to Child Care Health & Safety training (take online)
For more information, go to www.oregon.gov/delc/programs/pages/erdc-training.aspx.
After completing the above training:
• Complete and sign the attached Child Care Provider Listing Form using black or blue ink.
• Mail the form within 30 days from the date issued in the “ODHS branch use only” section. Mail
to the Direct Pay Unit at P.O. Box 14850, Salem, OR 97309-0850, fax to 503-378-5953 or email
DPU.childcarebilling@delc.oregon.gov (PDF only).
• Contact DPU for questions at 1-800-699-9074 (toll-free) or 503-378-5500 (Salem area).
• Complete the Central Background Registry (CBR) application to start the process for background
checks. To get the CBR application go to: www.oregon.gov/DELC or call CCLD at
1-800-556-6616 to get an application. For more information see page 9. You can either download,
print, and mail the application or fill out the online application and submit it electronically to CCLD.
Additional information for both relative and non-relative
license-exempt providers
Background checks
The Child Care Licensing Division (CCLD runs background checks through the Central
Background Registry (CBR).
Providers and household members will need to fill out the Central Background Registry (CBR)
application. CCLD will then conduct the background checks. To get the CBR application go
to: www.oregon.gov/DELC or call CCLD at
1-800-556-6616 to get an application.
Page IV of VI
DELC 7494d (07/2023) recycle prior versions
Background checks include fingerprints through both the Oregon State Police and the Federal Bureau
of Investigation (FBI). Checks also includes: criminal history check and sex offender check through the
Law Enforcement Database System (LEDS), Child Protective Services (CPS) and Adult Protective
Services (APS) history check through Oregon Department of Human Services, Oregon court records
check, and a check of the National Sex Offender Registry.
Individuals who have lived outside of Oregon within the last five (5) years of their CBR application
submission may receive state specific instruction for additional out of state checks. Background checks
are required for the provider, any member of the household who is age 18 or older, volunteers, and any
visitors to the home who may have unsupervised access to a child in care. A visitor is someone who
may spend time at the provider’s home during the time child care is provided but does not live in the
home. This is likely when the provider needs to visit another area of the home (bathroom, bedrooms,
kitchen), leaving the visitor an opportunity for unsupervised access to children.
» In facilities exempt from licensing, the site director and everyone who works in the facility who
will have access to the children in care need criminal and child protective service records
checks. This includes employees, substitute caregivers, staff and volunteers who may have an
opportunity for unsupervised access to children.
Important:
Providers and individuals will need to be enrolled in the CBR prior to being approved to receive child
care subsidy payments
Submit the CBR application to CCLD when submitting the Child Care Provider Listing form to DPU in
order for the background checks to be completed timely.
Instructions for CCLD licensed child care providers (registered
family, certified family, certified center)
Licensed providers with CCLD are required to:
• Meet ERDC provider requirements and health and safety standards.
• Complete and sign the attached Child Care Provider Listing Form using black or blue ink.
• Mail the form within 30 days from the date issued in the “ODHS branch use only” section.
Mail to the Direct Pay Unit at P.O. Box 14850, Salem, OR 97309-0850, fax to
503-378-5953 or email DPU.childcarebilling@delc.oregon.gov (PDF only).
A Child Care Provider Listing Form is required for each site where care is provided. DPU will need to
list and approve each site to receive subsidy child care payments.
Contact DPU for questions at 1-800-699-9074 (toll-free) or 503-378-5500 (Salem area). Child care
payments from DELC begin once the listing form has been approved and the family is eligible for child
care benefits.
Page V of VI DELC 7494d (07/2023) recycle prior versions
Important information for all
child care providers
Notice
The Oregon Department of Early Learning and Care (DELC) helps pay child care costs for families
receiving child care assistance. The family may have to pay for some of the care, including the first
month of service, if DELC does not approve their provider’s listing before their child starts care.
Providers are required to meet all DELC standards and provider requirements to be eligible for
payment from DELC. For full standards and requirements, see the ERDC Child Care Provider Guide
(DELC 7492) or visit www.oregon.gov/delc/providers.
• This is not a billing form. You will receive a billing form in the mail if DELC approves you to receive
payment as a child care provider and the parent is eligible for child care assistance.
• The family may also be responsible to pay for some of the care, including the first month of care.
• If there is more than one provider for a child, each provider will receive a percentage of the hours for
each month.
• For more information regarding child care, go to the DELC child care information website:
www.oregon.gov/DELC.
• By supplying your email address in #3 of the listing form, DELC will email you important information
on the child care program.
Important contacts
• Direct Pay Unit (DPU): P.O. Box 14850,
Salem, OR 97309-0850, 1-800-699-9074 (toll-free) or
503-378-5500 (Salem area) or email customerservice.dpu@delc.oregon.gov
• Child Care Licensing Division: 1-800-556-6616 or email CC[email protected]
» To get the CBR application go to: www.oregon.gov/DELC or call CCLD to get an application. For
more information see page 9. You can either download, print, and mail the application or fill out
the online application and submit it electronically to CCLD
• Child Care Resource and Referral Centralized Coordination: 1-800-342-6712 (toll-free).
They can help you fill out this form.
• 211 info: Dial 211 or
text the keyword “children” to 898211 or email [email protected]
• SEIU — Union for l icense
-exempt providers: 1-844-503-SEIU (7348)
• AFSCME — Union for CCLD l icensed providers: 1-800-521-5954
Reporting changes
All child care providers are required to report the following changes to DPU within five days by
calling 1-800-699-9074 or 503-378-5500 or by emailing DPU.ProviderReporting@delc.oregon.gov:
• Any new arrests, indictments, convictions or involvement with Child Protective Services (Child
Welfare) or any other agencies providing child or adult protective services by any of the following:
» You
» Any person living with you age 18 and older
Page VI of VI DELC 7494d (07/2023) recycle prior versions
» Visitors
» Each person supervising a child in the provider’s absence
» The site director of an exempt child care facility and anyone who works in the facility who has
access to the children in care, including employees, substitute caregivers, staff and volunteers
and
» Any other person required to be on the listing form.
• Any change to the provider’s name, phone number or address including any location where care
is provided
• Any new person (age 18 and older) in the home or facility, including visitors to the home or facility
during the hours care is provided who may have unsupervised access to the children in care
• If I am now licensed with CCLD or have changed my license type with CCLD
• If I am no longer licensed with CCLD
• If I no longer meet ERDC provider requirements including health and safety requirements
• If I am now a home care worker for any ODHS Aging and People with Disabilities programs or
personal support worker through any Intellectual and Developmental Disability (IDD) or Oregon
Health Authority (OHA) Behavioral Health Services program
• If I am a home care worker or personal support worker, I will notify DPU if any changes occur with
the type of care I provide or if clients have been added to my care
Failure to report changes may result in a fail status or suspension as a child care provider and you will
not be able to receive child care payments.
Frequ
ently asked questions and full standards and requirements
See the ERDC Child Care Provider Guide (DELC 7492) or visit: www.oregon.gov/DELC.
Where to submit the completed form
By mail: Direct Pay Unit, P.O. Box 14850, Salem, OR 97309-0850
By fax: 503-378-5953
By email: DPU.childcarebilling@delc.oregon.gov (PDF only)
Questions? Call 1-800-699-9074 (toll-free) or 503-378-5500 (Salem area)
Where to submit a completed Central Background Check
Registry application
Online Application: www.oregon.gov/DELC You can either download, print, and mail the application
or fill out the online application and submit it electronically to CCLD
By mail: Child Care Licensing Division, 700 Summer St. NE, Salem, OR 97301
Questions call CCLD at: 1-800-556-6616 or email CCLD.customerservice@delc.oregon.gov
you
r o
wn
home
.
)
Yes No
If yes, attach a letter from the ODHS foster care certifier approving you to do child care in that home or your
listing will be failed.
Page 1 of 11 DELC 7494d (07/2023) recycle prior versions
Child Care Provider Listing Form
All child care providers are
required to complete this form.
ODHS branch use only
DPU
DPU worker: Provider number: Notes:
Child care provider section — use blue or black ink
1. Name as it appears on IRS records: 2. SSN or IRS number: 3. Email:
4. Name to be printed on the check: 5. Address where you provide child care*: City: State: ZIP:
6. Phone number:
( )
-
7. Address where you live: City: State: ZIP:
8. What language do you prefer? 9. Mailing address (if different): City: State: ZIP:
* Note: If you provide child care at more than one address, attach a separate sheet of paper with the
additional addresses. License exempt facilities needs to submit a 7494 for each location where
care will be provided.
10.
Check this box if you are currently lic
ensed with the Child Care Licensing Division (CCLD).
Write your CCLD license number here: ________________________
11.
Check this box if you are a child care facility that is exempt from l
icensing with CCLD
12. Ethnicity:
Racial heritage:
Hispanic/Latino
Asian
Not Hispanic/Latino
White
American Indian/Alaska Native
Black or African American Native
Hawaiian/Pacific Islander
You can choose not to give the above ethnicity and racial heritage information. Your provider status will not
be affected.
13. Is the home where care is being provided foster care certified? (This applies if you provide care in
14. Do you provide (or will you provide) child care in the home where the child lives?
Yes No
PRE
-LIST
d) Are you working o
r a
pproved to be a personal support worker (PSW) through any ODHS
Intellectual and Development Disability (I/DD)? Yes No
e) If yes, write your provider number here even if you do not currently have clients:
Page 2 of 11 DELC 7494d (07/2023) recycle prior versions
15. a) Are you working or approved to be a homecare worker (HCW) through any Aging and People with
Disabilities (APD) programs? Yes No
b) If yes, write your provider number here even if you do not currently have clients:
c) Are you currently providing service for client(s) in APD programs?
Yes No
f) Are you currently providing service for client(s) in I/DD programs? Yes No
If you are a homecare
or personal support worker and you are currently servicing clients, please attach
a separate paper with your work schedules (days/times) for each type of care you provide (or will
provide), as well as the child care schedule. The listing form is incomplete and will be returned if
schedules are not attached. Additional information may be requested to determine child care
provider eligibility.
Notify DPU if changes occur with the type of care you provide or if you have added clients to your
care.
16. List the children of the ERDC families who will be in your care. (Attach a separate paper if necessary.)
Child’s name (first and last)
child in care:
Grandparent Great grandparent Sibling
Aunt or uncle (do not include great) Not related
Grandparent Great grandparent Sibling
Aunt or uncle (do not include great) Not related
Grandparent Great grandparent Sibling
Aunt or uncle (do not include great) Not related
*Relationships must be by blood, adoption or marriage. This includes biological relatives. Relationships
by marriage continue even if a spouse dies.
Please answer the following questions:
Yes No
Yes No
Yes No
17. I am the parent, stepparent or legal guardian of the child in care.
18. I am on the same Temporary Assistance to Needy Families (TANF)
case or
Employment Related Day Care (ERDC) case as the child.
19. I am a sibling and live in the same household of the child who will be in care.
20. I hold a medical marijuana card or distribute, grow or use marijuana (including
medical marijuana) or any controlled substance (except lawfully prescribed and
over-the-counter medications).
Yes No
If you answered “Yes” to any of the above questions, you are not eligible to be listed as an ERDC
child care provider. Do not proceed.
Birth date Check the correct box if you are a relative* of the
Page 3 of 11
DELC 7494d (07/2023) recycle prior versions
21. Basic provider requirements
All child care providers, including those licensed with CCLD are
Do you meet the
requirements?
A. If required by law, I will be licensed with the Child Care Licensing Division (CCLD).
See the page 1 of instructions section for more information.
Yes No
B. I am age 18 years of age or older and I understand that I am legally responsible
for the accuracy of this form and to repay any payment made in error.
Yes No
C. I am the actual person or facility providing care for the children. Yes No
D. I am competent and have sound judgement and self-control when working
with children.
Yes No
E. I am mentally, physically and emotionally capable of performing duties related
to child care.
Yes No
F. I will keep billing records and daily attendance records that show the check-in and
check-out times each day for each child in care (for no less than 12 months).
Yes No
G. If requested, I will allow DELC and ODHS to review billing records and attendance
records. I understand that I will incur an overpayment when attendance
records are not submitted for verification.
Yes No
H. I will treat ERDC families the same as other families receiving care
including charging ERDC families the same rate (or less) than I normally
charge non-ERDC families.
Yes No
I. I agree to have or develop a policy for removal and suspension of a child from
the child care setting and communicate this policy to parents/caregivers.
Yes No
J. I agree to complete the Foundation for Learning training within 90 days of
being approved if I am not required to be licensed with CCLD and am
not related to all children in care.
Yes No
N/A
K. I agree to complete the DELC Child Care Orientation Part 1 and Part 2
trainings within 90 days of being approved with DELC if I am not required
to be licensed with CCLD am a new provider or am relisting after a break
of one year or more.
Yes
No
N/A
L. I agree to complete an additional 6 hours of training each 2 years. Trainings
include 2 hours in Human Growth and Development & 2 hours in a core
knowledge category of my choice. I also agree to take an annual health &
Safety Training. These trainings are for providers not required to be licensed
with CCLD and not related to all children in care. See the Child Care Provider
Guide for more information.
Yes No
N/A
M. I will allow DELC and ODHS to inspect or visit the site of care during the hours
child care is provided.
Yes No
N. I will provide proof that I meet the DELC requirements when requested. Yes No
If you answered “No” to any of the above questions, you are not eligible to be listed as an ERDC
child care provider. Do not proceed.
required to answer this section.
Page 4 of 11 DELC 7494d (07/2023) recycle prior versions
22. Home/facility requirements
Does your
home/facility
meet the
requirements?
Yes No
A. Does each floor used by children have two u
sable outdoor exits? (This can
include a sliding door or window that can be used to evacuate children.)
1. If there is a second floor used for child care, I have or will have a written plan
for evacuating children.
Yes No
N/A
Yes No
B. Does the home/facility have safe water for drinking or preparing food?
1. If you are a license-exempt provider not related to all children in care, have
you attached the lead test results to this form? See the information page 2
for more information.
Yes No
N/A
C. Does the home/facility have a working smoke detector on each floor and in each
area where children nap?
Yes No
D. Will you ensure that the building, grounds, toys, equipment and furniture are
clean, sanitary and hazard-free?
Yes No
E. Does the home/facility have a working telephone? (You must note phone number
in question 6.)
Yes No
F. Are there barriers to protect children from fireplaces, space heaters, electric
outlets, wood stoves, stairways, pools, ponds and other hazards. All gates and
enclosures must not pose a risk or hazard to any child in care.
Yes No
G. Will you ensure that items dangerous to children are kept in a secure place out of
a child’s reach? These items include firearms, ammunition, alcohol, inhalants,
tobacco and e-cigarette products, matches and lighters, any legally prescribed
or over-the-counter medicine, cleaning supplies, paint, plastic bags, and
poisonous and toxic materials.
Yes No
If you answered “No” to any of the above questions, you are not eligible to be listed as an ERDC
child care provider. Do not proceed.
23. Promoting safety
All child care providers, including those licensed with CCLD are
required to answer this section.
Do you meet the
requirements?
A. I will make sure that no one smokes or carries any lighted smoking instrument,
including e-cigarettes and vaporizers:
• In the home or facility or within 10 feet of any entrance, exit, window that opens,
or any ventilation intake that serves an enclosed area, during child care
operational hours or anytime child care children are present and
• In motor vehicles when child care children are passengers.
Yes No
All child care providers, including those licensed with CCLD are
required to answer this section.
If CCLD does not require you to be licensed (exempt from licensing), there may
be help in meeting the following requirements. Please contact DPU for more
information. You may print a safety and quality reimbursement form at:
https://wou.edu/tri/forms/.
↓ Oregon Dhs Child Care Provider PDF Form

Document Characteristics

Fact Name Description
Form Purpose The Oregon DHS Child Care Provider Listing Form is designed to collect necessary information from child care providers for licensing and subsidy eligibility.
Licensing Requirement Child care providers must be licensed with the Office of Child Care (OCC) unless they meet specific license-exempt criteria.
License-Exempt Criteria Providers may be exempt from licensing if they care for three or fewer children, are related to the children, or do not care for children more than 70 days a year.
Water Testing License-exempt non-relative providers must test their water supply for lead before submitting the form, unless they provide care in the child's home.
Training Requirements Providers not related to all children in care must complete specific training, including Child Care Health & Safety and CPR/First Aid, before submitting the form.
Submission Timeline The completed form must be submitted within 30 days from the date indicated in the "ODHS branch use only" section.
Background Checks ODHS conducts FBI fingerprint background checks for all license-exempt child care providers and household members aged 16 and older.
Contact Information For assistance, providers can contact the Child Care Resource and Referral office at 1-800-342-6712 or the Direct Pay Unit at 1-800-699-9074.
Important Notices Families may need to cover initial child care costs if the provider's listing is not approved before care begins.
Governing Laws The Oregon DHS Child Care Provider Listing Form operates under Oregon Revised Statutes (ORS) related to child care licensing and safety standards.
Please rate Blank Oregon Dhs Child Care Provider Form Form
4.69
(Top-notch)
131 Votes

Fill out More Documents

Oregon 40 Esv - If you're making a tax payment for the first time in Oregon, this form includes a specific checkbox to indicate your status.

When dealing with trailer ownership transfers, a solid understanding of the Trailer Bill of Sale is vital for buyers and sellers alike. This essential document provides a formal record of the agreement, safeguarding both parties involved. For further details and to access the required form, visit the official Trailer Bill of Sale information page.

What Do They Do at a Dot Physical - Helps to regulate the medical fitness of Oregon CDL drivers, incorporating both national and state guidelines for safety.

Blank Oregon Dhs Child Care Provider Form

Open Editor Now