Self-declaration Process 620-01-30-01

(Revised 1/31/22 ML #3770)

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1. The applicant completes SFN 865.

2. Applicant obtains certification in pediatric CPR/AED and pediatric First Aid from an approved source.

3. Applicant submits completed SFN 865, cleared CBCU memorandums for emergency designee and household members over the age of 12, copies of pediatric CPR/AED and pediatric First Aid certification, and copies of pet vaccinations, if applicable, to their Licensing Specialist with the application fee.

4. Licensing Specialist completes pre-approval visit to the location where care is to be provided. Licensing Specialist documents visit on SFN 1595.

5. Licensing Supervisor reviews the complete application packet and documentation.

6. Licensing Specialist and Licensing Supervisor shall ensure provider documents are complete and saved in the state licensing system.

7. Licensing Supervisor approves or denies application. The earliest effective date of a self-declaration will be the date the Licensing Supervisor reviews and signs the completed application packet.

8. The Licensing Supervisor should contact the central office if there appears to be a problem with timely approval of SFN 865.

9. If approved, the self-declaration certificate is issued and a copy is saved in the state licensing system.

10. There shall be only one self-declaration per residence.

11. If there are new household members over the age of 12 after the application, the provider must submit a cleared CBCU memorandum for that household member.

 

Self-Declaration Renewal Timeline

• 120 days prior to the expiration date of a self-declaration certification: The Licensing Specialist will send the provider the Self-Declared Renewal Letter.

• 60 days prior to the expiration date of a self-declaration certification: All required documentation must be received. If all required documentation has not been received, the Licensing Specialist will send the provider the Past Due Renewal Notice.

• Upon the expiration date of a self-declaration certification: If all required documentation has not been received, the Licensing Specialist will send the provider a Did Not Renew Letter.