Blank Case Mix Report
15 June 2018
Blank form for Nursing Homes reporting Case Mix
Disabilities, Aging and Independent Living
Form
Survey and Certification Background Checks Notification
17 May 2017
Resident Assessment Form
15 February 2017
Survey & Certification Reporting Form
15 February 2017
Tax Compliance Form
15 February 2017
Therapeutic Community Residence New Facility Licensure Packet
15 February 2017
Residential Care Home New Facility Licensure Packet
15 February 2017
Assisted Living Residence - New Facility Licensure Packet
15 February 2017
CLIA Laboratory Certification
15 February 2017
Residential Care Transfer-Discharge Letter
15 February 2017
Pages
Contact Us
Division of Licensing and Protection
HC 2 South, 280 State Drive
Waterbury, VT 05671-2060
(802) 241-0344
For Telecommunications Relay Service: Dial 711
Adult Protective Services Reporting Line
(800) 564-1612
Healthcare Organization Complaint Reporting Line
(888) 700-5330
Clayton Clark
Division Director
Joe Nusbaum
Assistant Director Adult Protective Services
Suzanne Leavitt
Assistant Director Survey and Certification
Connect with Us
Limited English Proficiency (LEP)
This is a Division of the
Department of Disabilities, Aging and Independent Living
under the Agency of Human Services