Washington State Department of Social and Health Services Home page

Electronic DSHS Forms

You may download some DSHS forms. These are provided only if a DSHS program requests forms to be available electronically for public use. DSHS forms are available for electronic completion in different software; however, all DSHS forms below are available as Adobe Acrobat PDF files. This means you can open, view, and print each form. To open, view, and print PDF forms, you need to download the free Adobe Acrobat Reader.

If you do not have Microsoft Word, download Microsoft Viewer. This allows you to open, view, and print Word forms. If asked for a password when using Microsoft Word forms, select the cancel button to continue. Passwords prevent changes being made to the form's content.

Additionally, you may download the free Shana Informed filler to electronically complete Shana forms below. On opening your first Shana form, you will be asked to enter a registration key. Please enter 32064015014070671 (you only need to enter this once).

We do our best to ensure the links below are accurate; but, if you find a link which does not work, please contact Forms and Records Management.


Search tip: You may hold down the Ctrl key and type the F key to help find a specific form by number or key word. This will call up the "Find" dialogue box. Enter the number or title word(s) and select "Find Next."


Number Title Format
01-110 Protective Payee Report (Economic Services Administration) Word, PDF
01-110A Protective Payee Periodic Social Services Report (Economic Services Administration) Word, PDF
01-110C Protective Payee Report Continuation (Economic Services Administration) Word, PDF
01-210 Transmittal of Client Funds from the Protective Payee (Economic Services Administration) Word, Shana, PDF
02-327 JRA Work Request (Juvenile Justice and Rehabilitation Administration) Word, PDF
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) Word, PDF
02-528 Fair Hearing Withdrawal English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Serbo-Croatian, Somali, Spanish, Vietnamese
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (DDA) Word, PDF
02-573 Background check Identification Verification (Office of Deaf and Hard of Hearing) Word, PDF
02-574 Application for Advisory Body Appointment Word, PDF
02-578 TED Monthly Client Contact Report (Office of Deaf and Hard of Hearing) Word, PDF
02-586 Temporary Employment Hours Tracking Log Word, PDF
02-587 CLIP/CSO Communication Word, PDF
02-589 Companion Home Outside Employment Notification (Developmental Disabilities Administration) Word, PDF
02-592 Application for Approval of Interpreter Continuing Education Activity Word, PDF
02-611 Statement of Understanding: Mid-Certification Review English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
03-076 Employee Personal Property Damage/Loss Claim Word, PDF
03-077 Release of All Claims Word, PDF
03-133 Injury and Illness Incident Report Word, PDF
03-133A Supervisor's Review of Injury / Illness Incident Word, PDF
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee Word, PDF
03-374E Confidential Information, Fraud and Abuse (Community Services Division) Word, PDF
03-387 DSHS Notice of Privacy Practices for Client Medical Information
PDF Addendum: DSHS HIPAA Covered Programs
English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement PDF
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) Word, PDF
03-391 Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) Word, PDF
03-394 Supervisor's Review of Employee Report of Resident/Client Assault Word, PDF
03-478 Children's Administration Travel Authorization Word, PDF
04-220 Family Ancestry Chart (Children's Administration) English: Word, PDF

Other languages (PDF):
Laotian, Spanish (Word), Spanish Tagalog
04-220A Indian Heritage Questionnaire English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
04-416 DBHR Target Data Elements Assessment/Admission Setup Word, PDF
04-416A DBHR Target Data Elements Discharge Word, PDF
04-417 DBHR Target Detox Short Form Word, PDF
04-418 DBHR Target Treatment Activities Word, PDF
04-419 DBHR Target Client Support Activities (Non-Treatment) Word, PDF
04-420 DBHR Target Agency Staff Word, PDF
04-423 DBHR Target Change of Circumstances Word, PDF
04-432 Treatment Plan and Change Report (DASA) Word, PDF
04-436 DBHR Target Group Treatment Activities Word, PDF
04-437 DBHR Target Agency Support Activities (Non-Treatment) Word, PDF
04-438 DBHR Target Group Support Activities Word, PDF
04-442 Nursing Home Credit Balance Report
PDF Instructions
Excel, PDF
04-443 Character, Competence, and Suitability Evaluation for Unsupervised Access to Adults Word, PDF
04-444 DBHR Target Data Elements Waiting List - First Contact Word, PDF
05-010 Rule Exception Request Word, PDF
05-013 Request for Hearing English: Word, PDF
Other languages (PDF): Arabic, Bosnian, Cambodian, Chinese, Farsi, Ilocano, Japanese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
05-180 Federal Grant Application (Washington State Partnership Council on Juvenile Justice) Shana, Word, PDF
05-180B State Grant Application (Washington State Partnership Council on Juvenile Justice) Shana, Word, PDF
05-180C Juvenile Detention Alternatives Initiative Grant Application (Washington State Partnership Council on Juvenile Justice) Shana, Word, PDF
05-180E State Gang Prevention and Intervention Application (Washington State Partnership Council on Juvenile Justice) Shana, Word, PDF
05-180F Federal Grant Application - B (Washington State Partnership Council on Juvenile Justice) Shana, Word, PDF
05-210 Exceptional Cost Request (ECR) (Children's Administration) Word, PDF
05-210A Attachment A Exceptional Cost Foster Care (Children's Administration) Word, PDF
05-218 LIST Examination Application Word, PDF
05-234 Unit of Local Government (ULG) Application (JRA) Word, PDF
05-234A Unit of Local Government (ULG) Application Continuation (JRA) Word, PDF
05-246 Notice of Action Exception to Rule (Home and Community Services) English: Word, PDF
Other languages (PDF) Cambodian, Chinese, Farsi, Hungarian, Japanese, Korean, Kurdish, Laotian, Polish, Punjabi, Russian, Somali, Spanish, Tagalog, Ukrainian, Urdu, Vietnamese
06-123 Nursing Assistant Training and Testing Reimbursement Word, PDF
06-124 Cost of Care Adjustment Request (Developmental Disabilities Administration) Excel, PDF Instructions
06-125 Residential Allowance Request Excel
06-159 Psychologist and Sex Offender Treatment Provider Invoice (DDA) Word, PDF
06-160 Adoption Support Monthly Counseling Billing Word, PDF
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral Word, PDF
06-165 Extended Foster Care Denial Letter (Children's Administration Word, PDF
Other languages (PDF): Spanish, Spanish Word
06-166 Individual Training Plan (Division of Licensed Resources, Children's Administration) Word, PDF
06-168 Change in Licensed Bed Capacity - Increase (Enhanced Services Facility, Residential Care Services) Word, PDF
06-169 Change in Licensed Bed Capacity - Decrease (Enhanced Services Facility, Residential Care Services) Word, PDF
06-170 Funding and Expenditure Data (Juvenile Rehabilitation) Excel, PDF
07-066 CCSP Award/Change Letter English: Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Dinka, French, Japanese, Karen, Korean, Kurdish, Laotian, Marshallese, Oromo, Portuguese, Punjabi, Romanian, Russian, Rwanda, Samoan, Sinhalese, Somali, Spanish, Swahili, Tagalog, Tigrigna, Trukese, Turkish, Vietnamese
07-075 In-Home/Relative Provider
English: Word. PDF
Other languages (PDF): Russian, Somali, Spanish
07-076 Request for Information (Child Care Subsidy Programs) English: Word, PDF
Other languages (PDF): Amharic, Arabic, Armenian, Bengali, Burmese, Cambodian, Chinese, Dinka, Dzongkha, Haitian-Creole, Farsi, French, Japanese, Karen, Kinyarwanda, Kirundi, Korean, Kurdish, Laotian, Mandinka, Marshallese, Mongolian, Nepali, Oromo, Portuguese, Punjabi, Romanian, Russian, Samoan, Sinhalese Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Turkish, Trukese, Ukrainian, Urdu, Vietnamese
07-081 Participation Reimbursement Excel, PDF
07-086 Notice of Discharge (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
07-087 Eligibility Checklist for DDA State Supplementary Payments (SSP) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
07-090 Caregiver Monthly Mileage

English: Word, PDF
Other languages (PDF): Arabic Russian Spanish

07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
07-098 Self Employment Monthly Sales and Expense Worksheet (Economic Services Administration) Word, Excel, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Korean, Laotian, Oromo, Punjabi Russian, Somali, Spanish, Tigrigna, Vietnamese
07-101 School-Aged Children Change of Circumstances (Economic Services Administration) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Spanish, Spanish Word, Vietnamese
09-052 Affidavit of Forged Endorsement English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
09-097 Record of Official Actions (Juvenile Rehabilitation Administration) Word, PDF
09-341 Order of Parole Conditions (Juvenile Rehabilitation Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Samoan, Somali, Spanish, Vietnamese
09-508 Waiver of Statute of Limitations English: Word, PDF
Other languages (PDF): Cambodian, ILocano, Korean, Russian, Somali, Spanish, Tagalog, Tigrigna, Vietnamese
09-520 Request for Conference Board English: Word, PDF
Other languages (PDF): Japanese, Marshallese, Mien, Russian, Somali, Sorani, Spanish, Tagalog, Thai, Tigrigna, Tongan, Trukese, Vietnamese
09-536 Inquiry to Bureau of Indian Affairs (BIA) Word, PDF
09-537 Notice to Non-Federally Recognized or Canadian Indian Tribe or Band RE: Court Hearing Shana, PDF
09-539 Inquiry to Indian Tribe, Band, or Nation Word, PDF
09-539A Inquiry to Indian Tribe, Band, or Nation, and Notice of Incarceration of a Youth Word, PDF
09-653 Background Authorization English: Word, PDF
Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Chinese, Dinka, French, Farsi, Karen, Kayah, Kirundi Korean, Laotian, Marshallese, Nepali, Nuer, Oromo, Polish, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Swahili, Tagalog, Tigrigna, Trukese, Ukrainian, Vietnamese
09-705 Order of Continued Detention or Release (Juvenile Rehabilitation) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
09-706 Parole Revocation Petition (Juvenile Rehabilitation Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Samoan, Somali, Spanish, Vietnamese
09-713 Order Denying Parole Revocation Petition (Juvenile Rehabilitation) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
09-714 Order Revoking Parole (Juvenile Rehabilitation Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
09-746 Notice of Sex/Kidnapping Offender Registration Requirements Word, PDF
09-746A DSHS Sex/Kidnapping Offender Preregistration English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
09-747 Notification of Release (Juvenile Rehabilitation Administration) Word, PDF
09-747A Notification of Sex Offender Release (Juvenile Rehabilitation) Word, PDF
09-760 Motion, Declaration of Child's Return from Voluntary Foster Care Placement, and Order of Dismissal Word, PDF
09-761 Indian Identity Request English: Word, PDF
Other languages (PDF): Chinese, Croatian, French, Hmong, Indonesian, Japanese, Marshallese, Mien, Nepali, Portuguese, Punjabi, Russian, Somali, Spanish Word, Spanish, Tagalog, Thai, Tigrigna, Tongan, Vietnamese
09-762A Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Developmental Disabilities Administration) Word, PDF
09-765 Declaration of Adoption Facilitator - Indian Child Word, PDF
09-777 Indian Child: Compliance Checklist Word, PDF
09-808 JRA Notice and Finding of Financial Responsibility English: Shana, Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
09-809 WorkFirst Work Experience (WEX) Referral Word, PDF
09-810 WorkFirst Work Experience (WEX) Agreement Word, PDF
09-837 Disclosure of Confidential HIV/AIDS Information English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
09-860 Interpreter Services Core Provider Agreement Word, PDF
09-876 Permanency Planning Findings and Order (Child With a Developmental Disability) Word, PDF
Other languages (PDF): Spanish
09-877 Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
09-878 Order Approving Continued Out-of-Home Care (Child With a Developmental Disability) Word, PDF
Other languages (PDF): Spanish
09-892 Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
09-893 Periodic Review of Individual Service Plan (DDA) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
09-961 Nursing Assistant Training Program (NATCEP) Declaration of the Program Director Word, PDF
09-966 Authorization to Release Information to the Court (Children's Administration) Word, PDF
09-979 Marital History English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
09-995 Companion Home Contract Evaluation (DDA) Word, PDF
09-997 Adoption Support Worksheet English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Spanish Word, Spanish, Vietnamese
09-998 Application For The Adoption Support Program and/or Reimbursement of Adoption Finalization Costs English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Spanish Shana, Spanish, Vietnamese
10-016 Certification for License of Foster Home Word, PDF
10-017 Termination of Foster Home License Word, PDF
10-043 Family Home Study English: Word, PDF
Other languages (PDF): Spanish, Spanish Word
10-061 Child's Registration Word, PDF
10-083 EPSDT Assessment (Children's Administration) Word, PDF
10-104B Service Verification/Attendance Record For Alternative Living Providers (Developmental Disabilities Administration) Word, PDF
10-114 Adoption Data Card (Children's Administration) Word, PDF
10-161 Mental Health Evaluation and Treatment Application for Certification (Behavioral Health and Service Integration Administration) Shana, Word, PDF
10-166A Behavioral Rehabilitation Services Referral (Children's Administration) Word, PDF
10-182 Home Study File Checklist (Children's Administration) Word, PDF
10-182A Unlicensed File Checklist (Children's Administration) Word, PDF
10-183 Foster Home Inspection Checklist (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Spanish Word, Spanish
10-209 Application for Program Certification (Children's Administration) Word, PDF
10-210 Staff Statement of Qualifications (Children's Administration) Word, PDF
10-214 Preauthorization for Services (Children's Administration) Word, PDF
Other languages (PDF): Korean
10-217 Nurse Delegation: Nursing Assistant Credentials and Training Word, PDF
10-231 Adult Family Home (AFH) Placement Checklist (DDA) Word, PDF
10-232 Provider Referral Letter For Supported Living/Group Home Providers Word, PDF
10-232A Provider Referral Letter Word, PDF
10-234 Individual with Challenging Support Issues (DDA) Word, PDF
10-237 Notice of Transfer or Discharge (Residential Care) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-238 Request for an Administrative Hearing (Residential Care Services) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-241 Report to Protective Services (Juvenile Rehabilitation) Word, PDF
10-244 Shared Parenting Plan (DDA) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
10-246 Permanency Plan (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
10-248 Compliance Agreement English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
10-248A Compliance Agreement Continuation Word, PDF
10-255 Public Health Nurse (PHN) Summary and Recommendations Word, PDF
10-257 Voluntary Placement Services Foster Care Medical Team (FCMT) Communication (DDA) Word, PDF
10-258 Individual with Community Protection Issues (DDA) Word, PDF
10-261 Foster Care Rate Assessment English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
10-268 Pre-Placement Agreement (Developmental Disabilities Administration) Word, PDF
10-269 Alternative Living Services Plan and Provider Report (DDA) Word, PDF
10-270 Adult Family Home / Assisted Living Facility Admission Agreement(s) Attestation Word, PDF
10-272 Cross-System Crisis Plan (DDA)
Word, PDF
10-276 WTRS Consumer Response (Office of Deaf and Hard of Hearing) Word, PDF
10-277 Request for Children's Residential Services English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-290 Policy Agreement (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Spanish Word, Spanish, Vietnamese
10-294 Mandatory Report to Law Enforcement Word, PDF
10-301 Notification of Eligibility Review (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Tagalog, Vietnamese
10-326 Staffed Residential Rate Proposal Excel
10-327 Residential Staff Schedule Reporting Excel
10-328 Residential Site Approval Request (DDA) Word, PDF
10-329 Informed Consent for ICAP (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-330 Request For Legal Advice Word, PDF
10-331 DDA Mortality Review Part 1. Provider Report Word, PDF
10-334 Monitoring of Side Effects Scale (MOSES) (DDA) Word, PDF
10-335 Dyskinesia Identification System: DISCUS Rating (DDA) Word, PDF
10-337 Important Information for SSP Recipients and Their Payees (DDA) English: Word, PDF
Other languages (PDF): Arabic, Bosnian, Cambodian, Chinese, Japanese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-339 Nursing Care Consultant (NCC) Assessment (DDA) Word, PDF
10-348 Information Checklist (DDA) Word, PDF
10-349 Comprehensive Review Tool Word, PDF
10-351 Disclosure of Services (ADSA Boarding Homes) Word, PDF
10-353 Documentation Request for Medical or Disability Condition English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Swahili, Vietnamese
10-354 Family Home Study Application (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-356 Application for Peer Counselor Word, PDF
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A Word, PDF
10-360 Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B Word, PDF
10-361 Assisted Living Facility Resident List - Attachment C Word, PDF
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D Word, PDF
10-363 Assisted Living Facility Resident Group Meeting - Attachment E Word, PDF
10-365 Assisted Living Facility Resident Interview - Attachment G Word, PDF
10-366 Assisted Living Facility Other Contact Interview - Attachment H Word, PDF
10-367 Assisted Living Facility Environmental Observations - Attachment I Word, PDF
10-368 Assisted Living Facility Resident Record Review - Attachment J Word, PDF
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K Word, PDF
10-370 Assisted Living Facility Notes / Worksheet - Attachment L Word, PDF
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M Word, PDF
10-372 Assisted Living Facility Contract Requirements - Attachment N Word, PDF
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O Word, PDF
10-376 Password Change/Confirmation Request Nursing Home Facility Log-in PDF
10-377 Notification of Age Four (4) Eligibility Expiration- English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, German, Japanese, Karen, Korean, Laotian, Palauan, Polish, Portuguese, Russian, Samoan, Somali, Spanish Word, Spanish, Vietnamese
10-378 Notification of Age Ten (10) Eligibility Expiration English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-382 Naturalization Services Pre-Screening Word, PDF
10-389 Approved Sleeping Room List For Assisted Living Facilities Word, PDF
10-389A Additional Rooms List For Assisted Living Facilities Word, PDF
10-393 Cost Estimate Worksheet for Hearing Aids and Services Word, PDF
10-395 Intensive Family Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary Word, PDF
10-396 SSI Letter (DDA) Word, PDF
10-400 Information Request Letter English: Word, PDF
Other languages (PDF): Arabic, Armenian, Cambodian, Chinese, Farsi, French, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-402 Child Placing Agency Referral Word, Excel, PDF
10-403 Abuse/Neglect Reporting Requirement Information Word, PDF
10-405 Foster Home Re-Assessment Word, PDF
10-406 Employed Foster Parent Child Care Plan English: Word, PDF
Other languages (PDF): Korean, Spanish, Vietnamese
10-410 Adult Family Home License Application Word, PDF
10-411 Consumer Response: Do Not Hang Up Complaint Word, PDF
10-412 Adult Family Home License Relinquishment Letter Word, PDF
10-413 Application For Contract For Currently Licensed Boarding Home Word, PDF
10-416 Foster Home Monitoring Visit Word, PDF
10-417 Adult Family Home Caregiver Experience Attestation (CEA) Form A for Applicants for Licensure Word, PDF
10-418 Fostering Well-Being Care Coordination Referral Word, PDF
10-419 Licensing and Safety Supervision Plan For Site Specific Conditions Word, PDF
Other languages (PDF): Arabic, Spanish, Spanish Word
10-422 AFH Quality Improvement Initial Visit Word, PDF
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services Word, PDF
10-424 Voluntary Participation Statement (Developmental Disability Administration) Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
10-425 Respite Provider Reference Questionnaire English: Word, PDF
Other languages (PDF): Spanish
10-426 Respite Care Applicant Letter English: Word, PDF
Other languages (PDF): Spanish
10-427 School District Communication Word, PDF
10-428 Caregiver Support Plan (Children's Administration) Word, PDF
Other languages (PDF): Spanish
10-432 Extended Foster Care Program Participant Agreement (Children's Administration) Word, PDF
10-436 Foster Care License Renewal Notice (Children's Administration) Word, PDF
Other languages (PDF): Spanish
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility Word, PDF
10-438 Long-Term Care Partnership (LTCP) Asset Designation Word, PDF
10-441 Individuals: Subscription and Directory (Office of the Deaf and Hard of Hearing) Word, PDF
10-441LP Individuals: Subscription and Directory - Large Print (Office of the Deaf and Hard of Hearing) Word, PDF
10-442 Goal Setting and Action Plan Worksheet (Home and Community Services) Word, PDF
10-443 Organizations: Subscription and Directory (Office of the Deaf and Hard of Hearing) Word, PDF
10-444 Relative Caregiver / Suitable Other Placement Fact Sheet and Home Study Checklist (Children's Administration) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
10-448 Nurse Delegation Contract Monitoring Chart Audit Word, PDF
10-450 Statement of Qualifications and Verification of Issues Discussed (Children's Administration) Word, PDF
10-453 Household Safety Inspection for Unlicensed Relatives / Suitable Others (Children's Administration) Word, PDF >
Other languages (PDF): Spanish, Spanish Word
10-454 Children's Administration Caregiver Authorization Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-455 Medical Log (Children's Administration) Word, PDF
10-456 Mental Health Treatment Options Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-457 Medical and Treatment Letter for Relative Placement (Children's Administration) Word, PDF
10-458 Home Study Referral Notice (Children's Administration) Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-459 Courtesy Supervision Referral Checklist (Children's Administration) Word, PDF
10-460 Treehouse Educational Advocacy Referral (Children's Administration) Word, PDF
10-462 User Application and Agreement (Children's Administration) Word, PDF
10-463 FamLink Data Access Request / Change (Children's Administration) Word, PDF
10-464 FamLink Access Application and Agreement (Children's Administration) Word, PDF
10-466 Early Family Support Services Referral (Children's Administration) Word, PDF
10-467 ADSA Sentence / Copy Design Folstein MMSE (Home and Community Services) Word, PDF
10-469 Notice to Clients Who Employ An Individual Provider (Home and Community Services) Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-470 Children's Intensive In-Home Behavioral Support (CIIBS) Service Request (Developmental Disabilities Administration) Word, PDF
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration) Word, PDF
Other languages (PDF): Spanish, Spanish Word
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) Word, PDF
10-474 FAR Family Assessment (Children's Administration) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-475 Early Intervention Program (EIP) Exit Summary (Children's Administration) Word, PDF
10-476 Early Family Support Services (EIP) 90 Day Review (Children's Administration) Word, PDF
10-478 Early Family Support Services (EIP) Exit Summary (Children's Administration) Word, PDF
10-479 Early Intervention Program (EIP) 90 Day Review (Children's Administration) Word, PDF
10-480 Comprehensive Family Evaluation (Children's Administration) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
10-481 Health Action Plan Word, PDF
PDF Instructions
10-484 Youth Run Prevention Plan (Children's Administration) Word, PDF
10-485 Treehouse Education Advocacy Program Case Activity Report (Children's Administration) Word, PDF
10-486 Assisted Living Facility Food Service Observations - Attachment P Word, PDF
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q Word, PDF
10-488 Extended Foster Care Program Consent English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-489 Reproductive Health, HIV and STD Consent Agreement (Foster Well-Being Care Coordination Unit) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-490 Child Specific Contract Rate Proposal (Children's Administration) Word, PDF
10-491 Statement of Children’s Administration Worker Word, PDF
10-492 Service Referral (Children's Administration) Word, PDF
10-495 Case Review Feedback Summary (Children's Administration) Word, PDF
10-496 Family Assessment Response: Referral for Community Resources (Children's Administration) Word, PDF
Other languages (PDF): Amharic, Arabic, Bosnian, Cambodian, Chinese, Farsi, Hindi, Hmong, Korean, Laotian, Nepali, Punjabi, Romanian, Russian, Samoan, Somali, Spanish, Spanish Word, Swahili, Tagalog, Tigrigna, Vietnamese
10-497 Continuous Quality Improvement (CQI) Action Plan (Children's Administration) Word, PDF
10-498 Completion of your Family Assessment Response (FAR) Case (Children's Administration) Word, PDF
Other languages (PDF): Amharic, Arabic, Bosnian, Cambodian, Chinese, Farsi, Hindi, Hmong, Laotian, Nepali, Punjabi, Romanian, Russian, Samoan, Somali, Spanish Word, Spanish, Swahili, Tagalog, Tigrigna, Vietnamese
10-499 Education Plan (Children's Administration) Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Tagalog, Vietnamese
10-500 Acknowledgement of Child(ren)’s Adoptive File Provided to Adoptive Family (Children's Administration) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
10-501 Referral to DSHS for Basic Food Employment and Training (BFET) English: Word, PDF
10-502 Service Intervention Plan (Children's Administration) English: Word, PDF
10-503 Limitation Extension Evaluation (Developmental Disabilities Administration) English: Word, PDF
10-504 Limitation Extension Request for Clients Under Age 21 (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-505 Limitation Extension Task Explanation (Developmental Disabilities Administration) English: Word, PDF Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-506 Limitation Extension Request Checklist (Developmental Disabilities Administration) English: Word, PDF Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
10-507 Orientation Sign-In Sheet (Children's Administration) English: Word, PDF
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280 (Residential Care Services) (Aging and Long-Term Support Services Administration)) English: Word, PDF
Instructions
10-509 Pediatric Symptom Checklist (PSC-17 (Home and Community Services) (Aging and Long-Term Support Services Administration) English: Word, PDF
10-510 Comprehensive Review: BRS / Contracts Program Review (Division of Licensed Resources) English: Word, PDF
10-511 Comprehensive Review: DLR Program Review (Division of Licensed Resources) English: Word, PDF
10-512 Comprehensive Review: BRS Contractor Client File (Division of Licensed Resources) English: Word, PDF
10-513 Comprehensive Review: DLR Client File (Division of Licensed Resources) English: Word, PDF
10-514 Comprehensive Review: Personnel Files (Division of Licensed Resources) English: Word, PDF
10-515 CA Worker Questionnaire (Division of Licensed Resources) English: Word, PDF
10-516 Youth Interview (Division of Licensed Resources) English: Word, PDF
10-517 Staff Interview (Division of Licensed Resources) English: Word, PDF
10-518 Foster Parent Interview (Division of Licensed Resources) English: Word, PDF
10-519 Incident Report Review (Division of Licensed Resources) English: Word, PDF
10-520 Comprehensive Review Final Report (Division of Licensed Resources) English: Word, PDF
10-521 Comprehensive Review: Compliance Agreement (Division of Licensed Resources) English: Word, PDF
10-522 Comprehensive Review: Immediate Action Plan Compliance Agreement (Division of Licensed Resources) English: Word, PDF
10-523 Orientation and Development Progress Report (Residential Care Services) English: Word, PDF
10-524 Session 1 Practice Recordt (Residential Care Services) English: Word, PDF
10-525 Session 2 Practice Record (Residential Care Services) English: Word, PDF
10-526 Session 3 Practice Record (Residential Care Services) English: Word, PDF
10-527 Preparation for Compliance Survey (Residential Care Services) English: Word, PDF
10-528 Observational Surveys (Residential Care Services) English: Word, PDF
10-529 Session 1 Participatory Survey (Residential Care Services) English: Word, PDF
10-530 Session 2 Participatory Survey (Residential Care Services) English: Word, PDF
10-531 Session 3 Participatory Survey (Residential Care Services) English: Word, PDF
10-532 Team Coordinator Survey (Residential Care Services) English: Word, PDF
10-533 First Compliance Survey Results (Residential Care Services) English: Word, PDF
10-534 Second Compliance Survey Results (Residential Care Services) English: Word, PDF
11-019 Vocational Information (Division of Vocational Rehabilitation) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
11-022 Application for Vocational Rehabilitation Services English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Ukrainian, Vietnamese
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP) (Division of Vocational Rehabilitation) Word, PDF
11-045 Work Experience (WEX) Referral (Food Stamp Employment and Training) Word, PDF
11-046 Work Experience (WEX) Agreement (Food Stamp Employment and Training) Word, PDF
11-055 Acknowledgement of My Responsibilities as the Employer of Individual Providers (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Arabic, Armenian, Bosnian, Bulgarian, Burmese, Cambodian, Chinese, Farsi, Hindi, Hmong, Karen, Korean, Laotian, Nepali, Punjabi, Romanian, Russian, Samoan, Serbo Croatian, Somali, Spanish, Ukrainian, Vietnamese
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) Word, PDF
11-066 Assistive Listening Device(s) (ALD) Sign-Out Register (Office of Deaf and Hard of Hearing) Word, PDF
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation) Excel, PDF
11-068 DVR Internship Application (Division of Vocational Rehabilitation) Word, PDF
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation) Word, PDF
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) Word, PDF
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) Word, PDF
11-072 DVR Internship Evaluation (Division of Vocational Rehabilitation) Word, PDF
11-078 Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation) Word, PDF
11-079 Centers for Independent Living (CILs), Title VII, Part B Annual Report (Division of Vocational Rehabilitation) Word, PDF
11-080 Centers for Independent Living (CILs), Title VII, Part B Monthly Report (Division of Vocational Rehabilitation) Word, PDF
11-084 Employees Approved to Provide IL Services and Type of Service Provided (Division of Vocational Rehabilitation) Word, PDF
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing) Word, PDF
11-094 User Agreement (Office of the Deaf and Hard of Hearing) Word, PDF
11-094LP User Agreement (Large Print) (Office of the Deaf and Hard of Hearing) Word, PDF
11-095 National Deaf-Blind Equipment Distribution Program (NDBEDP) Client Complaint (Office of the Deaf and Hard of Hearing) Word, PDF
11-097 Service Delivery Outcome Report (Independent Living - IL) (Division of Vocational Rehabilitation) Word, PDF
12-006 Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program PDF Instructions
PDF 1 - 10 persons
PDF 11 - 20 persons
12-195 Food Assistance Program Disqualification Consent Agreement English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
12-206 Application for Disaster Food Stamp Assistance English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
12-207 Application for Disaster Cash Assistance English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
13-001 Applicant Medical Report - Confidential Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
13-021 Physical Functional Evaluation Word, PDF
13-041 Child's Medical and Family Background Report (Children's Administration) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
13-433 Transfer/Discharge Health Summary (Juvenile Rehabilitation) Word, PDF
13-585A Incapacity Range of Joint Motion Chart Word, PDF
Other languages (PDF): Tigrigna
13-628 Involuntary Treatment Act Patient Claim Information Word, PDF
13-645 Adult Family Home Injuries and Accidents Log Word, PDF
13-677 Naltrexone Authorization Word, PDF
13-678 Page 1 Nurse Delegation: Consent for Delegation Process English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task Word, PDF
13-678A Nurse Delegation: PRN Medication Word, PDF
13-678B Nurse Delegation: Assumption of Delegation Word, PDF
13-680 Nurse Delegation: Rescinding Delegation Word, PDF
13-681 Nurse Delegation: Change in Medical Orders Word, PDF
13-690 Medical Services Authorization (Juvenile Rehabilitation) Word, PDF
13-692A Assisted Living Facility (ALF) Dementia Screening Tool Word, PDF
13-712 Medicaid Personal Care Client RSN Transmittal Word, PDF
13-713 Fast Track Service Agreement Word, PDF
13-720 Suboxone Authorization Word, PDF
13-734 Documentation of First Use of Medicaid Benefits (DDA) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
13-737 Washington Medicaid Integration Partnership (WMIP) AI/AN Exemption/Disenrollment Request Shana, PDF
13-738 DDA / CA Request to Cost Share Word, PDF
13-749 Campral Authorization (Division of Behavioral Health and Recovery) Word, PDF
13-750 Suboxone Exemption Request (Division of Behavioral Health and Recovery) Word, PDF
13-776 Nursing Services Referral Word, PDF
13-784 Nursing Services Assessment Word, PDF
13-791 Vivitrol IM Physician Prior Authorization Word, PDF
13-830 ICF/ID Admissions Review Team Checklist Word, PDF
13-851 Psychiatric Referral Summary Word, PDF
13-851A Psychoactive Medication Treatment Plan Word, PDF
13-851C Psychoactive Medication Treatment Plan Annual Continuation of Medication Word, PDF
13-865 Psychological/Psychiatric Evaluation Word, PDF
PDF Guidelines
13-893 Nurse Delegation: Request For Additional Units Word, PDF
13-899 Review of Medical Evidence Word, PDF
13-901 Buprenorphine Authorization for Pregnancy Word, PDF
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) Word, PDF
13-905 Autistic Disorder Confirmation (Developmental Disability Administration) Word, PDF
13-906 Therapy Assessment Bed Rails or Side Rails (Home and Community Services) Word, PDF
14-001 Application for Benefits English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-012 Consent English: Word, PDF
Other languages (PDF): Albanian, Amharic, Arabic, Armenian, Bosnian, Bulgarian, Burmese, Cambodian, Chinese, Farsi, Finnish, French, German, Hindi, Hmong, Hungarian, Ilocano, Indonesian, Japanese, Karen, Korean, Kurdish, Laotian, Marathi, Marshallese, Mien, Mongolian, Nepali, Oromo, Polish, Portuguese, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Sudanese, Swahili, Tagalog, Thai, Tigrigna, Tongan, Trukese, Turkish, Ukrainian, Urdu, Vietnamese
14-050 Statement of Health, Education, and Employment English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-057 Child Support Referral English: Word, PDF
Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Cantonese, Chinese, Farsi, French, Italian, Ilocano, Japanese, Korean, Laotian, Malayalam, Marshallese, Mien, Mongolian, Nepali, Norwegian, Oromo, Portuguese, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Ukrainian, Vietnamese
14-057B Noncustodial Parent Child Support Enforcement Application English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Korean, Somali, Spanish, Tigrigna
14-068 Financial Statement (Division of Vocational Rehabilitation) English: Excel, PDF
Other languages (PDF): English, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-076 Change of Circumstances English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-078 Eligibility Review English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-084 Financial/Social Services Communications Word, PDF
14-113 Your Rights and Responsibilities English: Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Farsi, Korean, Laotian, Marshallese, Nepali, Punjabi, Russian, Somali, Spanish, Tigrigna, Vietnamese
14-118A ADATSA Incapacity Decision/Disposition Word, PDF
14-144A Medical Disability Decision English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Polish, Russian, Somali, Spanish, Vietnamese
14-151 Request for DDA Eligibility Determination English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, German, Korean, Laotian, Polish, Punjabi, Romanian, Russian, Samoan, Somali, Spanish Word, Spanish, Swahili, Tagalog, Vietnamese
14-155 Senior Citizens Service Application Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish Word, Spanish, Vietnamese
14-162 Veteran's Referral Word, PDF
14-191 Personal Employment Plan (PEP) - Application and Referrals (Refugee Assistance) Word, PDF
14-222 Statement of Collateral Information English: Word, PDF, Translated Summary
Other languages (PDF): Albanian, Amharic, Arabic, Bengali, Cambodian, Chinese, Farsi, French, Indonesian, Japanese, Korean, Kurdish, Laotian, Nepali, Portuguese, Punjabi, Romanian, Russian, Somali, Spanish, Swahili, Tagalog, Tigrigna, Trukese, Vietnamese
14-223 Statement from School Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-224 Statement from Landlord/Manager English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Karen, Korean, Laotian, Mien, Romanian, Russian, Somali, Spanish, Tagalog, Tigrigna, Tongan, Urdu/a>, Vietnamese
14-225 Acknowledgement of Services English: Word, PDF
Other languages (PDF): Albanian, Amharic, Arabic, Armenian, Bosnian, Cambodian, Chinese, Farsi, Hindi, Ilocano, Indonesian, Italian, Japanese, Korean, Kurdish, Laotian, Mien, Marshallese, Nepali, Oromo, Polish, Punjabi, Romanian, Russian, Samoan, Serbo Croatian, Somali, Spanish Word, Spanish, Tagalog Tigrigna, Tongan, Turkish, Ukrainian, Urdu, Vietnamese
14-238 Client Income Report Word, PDF
14-245 Education List Checklist (Juvenile Rehabilitation Administration) Word, PDF
14-251 Statement of Applicant / Recipient or Other Person (Burial Fund Provision SSI Related) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-251A Statement of Applicant / Recipient or Other Person (Irrevocable Burial Fund Provision SSI Related) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-252 Employment Verification English: Word, PDF
Other languages (PDF): Amharic, Arabic, Armenian, Bengali, Burmese, Cambodian, Chinese, Farsi, French, Haitian-Creole, Hindi, Hmong, Farsi, French, Ilocano, Gujarati, Japanese, Kirundi Korean, Kurdish, Laotian, Marshallese, Mongolian, Nepali, Oromo, Portuguese, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Turkish, Ukrainian, Vietnamese
14-264 Application for Telecommunications Equipment Word, PDF
14-281 Source of Funds Application for Child in Placement Word, PDF
14-293 Title IVE Initial Eligibility Determinations: Income Calculation Worksheet (Children's Administration) Excel, PDF
14-299 ADATSA/Adult Assessment Referral Word, PDF
14-300 Level One Pre-Admission Screening and Resident Review (PASRR) Word, PDF
14-310 Client Status Change Report Word, PDF
14-311A Assessment Center Summary for TANF Word, PDF
14-319 Title IVE Initial Eligibility Determination for an Adoption Support Application (CA) Word, PDF
14-332 Disability Assessment Word, PDF
14-338 Level II: Initial Psychiatric Evaluation Summary Information Word, PDF
14-339 Level II: Follow-Up or Significant Change Psychiatric Evaluation Summary Information Word, PDF
14-349 Protective Payee Assessment English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Korean, Laotian, Marshallese, Punjabi, Russian, Somali, Spanish, Vietnamese
14-369 Nursing Assistant Training Program (NATCEP) Instructional Staff Applications Word, PDF
14-370 Nursing Assistant Training Program (NATCEP) Application for Program Director Word, PDF
14-371 Nursing Assistant Training Program (NATCEP) Application for Approval Word, PDF
14-381 WorkFirst Individual Responsibility Plan English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Lingala, Russian, Somali, Spanish, Vietnamese
14-401 Notification of Address Disclosure Request - Part 1 English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
14-401A Notification of Address Disclosure Request - Part 2 English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
14-402 Notice to Parents (WorkFirst)
English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
14-413 Level II: Invalidation Statement, Statement and Criteria of Non-Completion Word, PDF
14-413A Level II: Invalidation Statement: Documentation for Interrupted Evaluation Word, PDF
14-416 Eligibility Review for Long Term Care Benefits (Aging and Long-Term Support Administration English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Hungarian Italian Korean, Laotian, Polish, Russian, Somali, Spanish, Spanish Word, Vietnamese
14-417 Child Care Subsidy Programs (CCSP) Application English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Japanese, Korean, Laotian, Marshallese, Oromo, Punjabi, Russian, Samoan, Somali, Spanish, Tigrigna, Tigrigna, Vietnamese
14-417A In-Home/Relative Pending Letter (Child Care Subsidy Program) English: Word, PDF
Other languages (PDF): Arabic, Burmese, Cambodian, Chinese, French-Creole, Kirundi Korean, Laotian, Nepali, Oromo, Punjabi, Russian, Samoan, Somali, Spanish, Sudanese, Swahili, Tigrigna, Trukese, Ukrainian, Vietnamese
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice English: Word, PDF Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Korean, Laotian, Marshallese, Russian, Somali, Spanish, Vietnamese
14-427 Teen Parent Living Assessment
PDF Instructions
Word, PDF
14-431 Medical/Dental Services Authorization English: Word, PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian,, Russian, Somali, Spanish, Vietnamese
14-432 Direct Deposit Enrollment English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-434 Title IV-E Requirements for Out of State Foster Care Payments (Children's Administration) Word, PDF
14-435 Provider Employment Eligibility Verification (Children's Administration) Word, PDF
14-436 Statement of Adult Acting in Loco Parentis (As a Parent) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian Russian, Somali, Spanish, Vietnamese
14-438 Stop Work English: Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, French, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-439 WASHCAP Application English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing) Word, PDF
14-443 Financial/Social Services Communication (Home and Community Services) Word, PDF
14-444 Child Health and Education Tracking Screening Report (Children's Administration) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
14-445 Nursing Assistant Training Program (NATCEP) Application for Renewal (Aging and Long-Term Support Administration) Word, PDF
14-445 PILOT PILOT: Nursing Assistant Training Program (NATCEP) Application for Renewal (Aging and Long-Term Support Administration) Word, PDF
14-446 Declaration of Financial Status (Children's Administration) Word, PDF
14-448 ADATSA Request for Exception to Contract Word, PDF
14-452 Financial Worksheet (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-453 Protective Payee Decision English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-454 Estate Recovery: Repaying the State for Medical and Long Term Care (LTC) English: PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Farsi, Hindi, Hmong, Ilocano, Indonesian, Japanese, Korean, Laotian, Nepali, Oromo, Punjabi, Polish, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Tigrigna, Toncan, Ukrainian, Vietnamese
14-459 Eligible Conditions Specific to Age and Type of Evidence (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, German, Korean, Laotian, Polish, Romanian, Russian, Samoan, Somali, Spanish, Spanish Word, Swahili, Tagalog, Vietnamese
14-460 Notice of Insufficient Information (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-462 Epilepsy Verification Request (Developmental Disabilities Administration) Word, PDF
14-463 Waiver Transportation Record (DDA) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-465 Sources For Eligibility Information (DDA) English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Shana, Spanish, Vietnamese
14-467 Mid-Certification Review English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-473 ICAP Letter English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-474 Shared Planning Meeting English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-478 Treatment Verification Request English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Punjabi, Russian, Somali, Spanish, Vietnamese
14-479 DASA Target Data Element - Gain Short Screening Setup Word, PDF
14-484 Nurse Delegation: Nursing Visit Word, PDF
14-485 GAIN-SS (Mental Health) English: Word, PDF
Other languages (PDF): Russian, Russian Word, Spanish, Spanish Word,
14-489 SSIF Introduction Letter English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-491 NSA Representative Checklist For AAG Authorization Word, PDF
14-492 Assessment Meeting Wrap-up English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-493 Requirement to Identify a Representative English: Word, PDF,
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
14-495 Naturalization Letter English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Ilocano, Korean, Laotian, Russian, Serbo-Croatian, Somali, Spanish, Vietnamese
14-496 Naturalization Appointment Letter English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-501 Community Resource Declaration Word, PDF
14-502 SSI Hearing Denial English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-503 Interim Assistance Reimbursement Agreement Cover English: Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Croatian, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Tigrigna, Vietnamese
14-505 Application for Deaf-Blind Communicator (DBC) Word, PDF
14-510 Respite Provider Policy Agreement English: Word, PDF
Other languages (PDF): Spanish Word, Spanish,
14-512 Application For Respite Provider Approval English: Word, PDF
Other languages (PDF): Spanish Word, Spanish,
14-513 Respite Care Provider Cover Letter English: Word, PDF
Other languages (PDF): Spanish Word Spanish,
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center English: Word, PDF
Other languages (PDF): Spanish Word Spanish,
14-515 Notice and Finding of Responsibility English: PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-517 DSHS Letter Requesting Non Work SSN Word, PDF
14-520 Your DSHS Cash or Food Benefits English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Marshallese, Russian, Somali, Spanish, Vietnamese
14-521 Your Rights (Home and Community Services) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Japanese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Ukrainian, Vietnamese
14-522 Chemical Dependency Good Cause Letter English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-525 Incapacity Review for Medical Care Services English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-526 Chemical Dependency Treatment Verification Request English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-527 Medical Care Services Case Plan English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-528 Chemical Dependency NonCooperation English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-529 Chemical Dependency Requirement English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
14-530 Disability Review English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Tigrigna, Urdu, Vietnamese
14-531 Education and Training Voucher (ETV) Program andPassport to College Promise Scholarship 2013 - 2014 Application Word, PDF
14-532 Authorized Representative English: Word, PDF
Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Greek, Korean, Laotian, Russian, Serbian, Somali, Spanish, Vietnamese
14-533 National Deaf-Blind Equipment Distribution Program Application
PDF Instructions , Text Instructions
Word, Text, PDF
14-533LP National Deaf-Blind Equipment Distribution Program Application (Large Print)
PDF Instructions
Word, PDF
14-534 SDCP Eligibility Checklist (Home and Community Services) Word, PDF
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-031 Notice of Action - Adult Residential Services Word, PDF
15-051 Individual Provider Time Sheet English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Farsi, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-092 ICPC Placement Request Word, PDF
15-093 Interstate Compact on the Placement of Children Report on Child's Placement Date or Change of Placement - 100B (Children's Administation) Word, PDF
15-184 Volunteer Chore Service Referral Word, PDF
15-209C Visiting Plan English: Word, PDF
Other languages (PDF): Arabic, Chinese, Cambodian, Punjabi, Serbo-Croatian, Spanish, Somali, Tagalog
15-215 AFH Quality Improvement Visit Assessment Word, PDF
15-243 Social Services Case Reading Guide Word, PDF
15-245 LEP Client Service Record (Limited English Proficient) Word, PDF
15-247 Working Connections Child Care (WCCC) Termination Notice English: Word, PDF
Other languages (PDF): Amharic, Arabic, Armenian, Burmese, Cambodian, Chinese, Farsi, French, French-Creole, Japanese, Kinyarwanda, Korean, Laotian, Marshallese, Oromo, Punjabi, Russian, Samoan, Somali, Sorani Spanish, Swahili, Tigrigna, Turkish, Trukese, Ukrainian, Vietnamese
15-247A Working Connections Child Care (WCCC) Denial Notice English: Word, PDF
Other languages (PDF): Albanian, Amharic, Arabic, Burmese, Cambodian, Chinese, Farsi, Hindi, Korean, Laotian, Marshallese, Nepali, Oromo, Pashtu, Portuguese, Punjabi, Russian , Serbo-Croatian, Sinhalese, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Ukrainian, Vietnamese
15-252 DRW Access Request Checklist Word, PDF
15-255 Medicaid Personal Care Provider Experience and Training Statement (Children's Administration) Word, PDF
15-258 Safety Assessment English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Tagalog, Vietnamese
15-259 Safety Plan English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-260 Parent Information Sheet For Shared Planning Meetings and Staffings English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish Word, Spanish, Vietnamese
15-266 CPT Staffing Recommendations English: Word, PDF
Other languages (PDF): Spanish Word, Spanish, Vietnamese
15-268 CPT Case Presentation Summary Word, PDF
Other languages (PDF): Spanish Word, Spanish
15-274 Assistance Available Schedule (DDA) Word, PDF
15-276 Personal Information (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
15-280 Unlicensed Caregiver Placement Checklist (Children's Administration) Word, PDF
Other languages (PDF): Russian, Spanish Word, Spanish
15-281 Placement Agreement (Children's Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
15-282a Request for Enrollment in Developmental Disability Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change From One DDA HCBS Waiver to Another English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-286 Reference Questionnaire (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Somali, Spanish, Spanish Word, Vietnamese
15-290 Notification of Annual Assessment Review Word, PDF
15-291 Client Notification of Annual Assessment Meeting English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-295 Waiver Individual Support Plan Meeting Survey English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-300 Child Information and Placement Referral English: Word, PDF Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration) English: Word, PDF
Other languages (PDF): Cambodian, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-308 Missing Child Staffing Word, PDF
15-309 Returning Child De-Briefing Word, PDF
15-313 Caregiver's Report to the Court English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Punjabi, Russian, Somali, Spanish, Vietnamese
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist Word, PDF
15-318 DDA Crisis Diversion Bed Referral and Intake Information Word, PDF
15-322 Long Term Care Agreement For Foster Parents or Relative Caregivers English: Word, PDF
Other languages (PDF): Spanish Word, Spanish, Vietnamese,
15-323 Checklist For Approval Long Term Care Agreement For Foster Parents or Relative Caregivers Word, PDF
15-324 Guardianship Approval Checklist Word, PDF
15-331 Annual Assessment Checklist (Developmental Disability Administration) Word, PDF
15-342 Notice of Exception to Rule Decision English: Word, PDFF
Other languages (PDF): Cambodian, Chinese, Kirundi, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Swahili, Vietnamese
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log PDF
15-356 DDA Community Protection Program Chaperone Agreement Word, PDF
15-357 Residential Services Opening Description Word, PDF
15-358 Client Referral Information Word, PDF
15-359 Child's Physical Description Word, PDF
15-360 Residential Services Capacity Profile Word, PDF
15-361 Individual and Family Services Program Request List - No Response English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-362 Concurrent TANF Benefits / Family Reunification Notice of Removal from TANF Home (Children's Administration) Word, PDF
15-365 Community Protection Treatment Worksheet Quarterly Review Word, PDF
15-366 Change of Address (DDA) Word , PDF
15-367 Administrative Review Request For Crime and/or Negative Action Word, PDF
15-368 Education and Training Voucher (ETV) Program Participation Agreement Word, PDF
15-369 Educational and Training Voucher (ETV)Program Renewal Application Word, PDF
15-370 Education and Training Voucher (ETV) Program Payment Request Word, PDF
15-372 Enumeration Referral Word, PDF
15-374 Physician Certification For Child/Youth With Developmental Disabilities to Maintain Their Permanent Residence Word, PDF
15-375 Home Study Referral for Contracted Services Word, PDF
15-376 Skin Observation Protocols English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-377 Education and Training Voucher (ETV) Program Dual Credit Application Word, PDF
15-379 Vendor Request for Staff Add-On (DDA) Word, PDF
15-380 Individual and Family Services Assessment Worksheet English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
15-381 Respite Assessment Worksheet Word, PDF
15-382 Positive Behavior Support Plan (PBSP) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
15-383 Functional Behavioral Assessment (FA) English: Word, PDF
Other languages (PDF): Spanish Word, Spanish
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) Word, PDF
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP Word, PDF
15-387 Respite Application - Licensed Staffed Residential/Foster Home Word, PDF
15-388 Alternative Living Review and Evaluation Word, PDF
15-389 Certified Community Residential Services and Support Application Word, PDF
15-398 Medically Intensive Children's Program (MICP) Application Word, PDF
15-402 Notice to Foreign Consulate of Child Protection Proceedings Word, PDF
15-411 Licensing Waiver/Administrative Approval Word, PDF
15-419 Refusal of Services Statement Word, PDF
15-420 Request For ICF/ID Admission Word, PDF
15-422 No Paid Services Group English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Ukrainian, Spanish, Vietnamese
15-424 Staffed Residential Cost of Care Adjustment Request Word, PDF
15-428 Protective Action(s) Plan (Children's Administration) Word, PDF
Other languages (PDF): Arabic, Cambodian, Laotian, Russian, Spanish, Spanish Word, Tagalog
15-430 Seasonal Child Care (SCC) Termination Notice English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
15-430A Seasonal Child Care (SCC) Denial Notice English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian , Somali, Spanish, Vietnamese
15-431 Voluntary Placement Agreement for Extended Foster Care Services English: Word, PDF
15-432 Educational Liaison's Report to the Court (Children's Administration) English: Word, PDF
Other languages (PDF): Spanish
15-433 Incomplete Application (Children's Administration) English: Word, PDF
15-434 On-Going Mental Health (OMH) Screening Report (Children's Administration) English: Word, PDF
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration English: Word, PDF
15-436 Pregnant Women Assistance (PWA) Chemical Dependency Requirement (Community Services Division) English: Word, PDF
15-437 Staff Orientation Checklist (Residential Care Services) English: Word, PDF
15-438 Inspection (Assisted Living Facility) English: Word, PDF
15-439 Follow-Up / Monitoring Inspection (Assisted Living Facility) English: Word, PDF
15-440 Complaint Investigation (Assisted Living Facility) English: Word, PDF
15-441 Team Coordination (Assisted Living Facility) English: Word, PDF
15-444 Re-Inspection (Adult Family Home) English: Word, PDF
15-445 Follow-up / Monitoring Inspection (Adult Family Home) English: Word, PDF
15-446 Complaint Investigation (Adult Family Home) English: Word, PDF
16-072 NonAssistance Support Enforcement Information (Division of Child Support) English: PDF
Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Cantonese, Chinese, Farsi, French, Hmong, Italian, Japanese, Korean, Laotian, Malayalam, Marshallese, Oromo, Portuguese, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Ukrainian, Vietnamese
16-107 Noncustodial Parent's Rights and Responsibilities English: PDF
Other languages (PDF): Armenian, Amharic, Arabic, Bambara, Bengali, Bulgarian, Burmese, Cambodian, Cantonese, Chinese, Farsi, German, Greek, Hmong, Ilocano, Italian, Karen, Korean, Laotian, Marshallese, Mongolian, Nepali, Oromo, Punjabi, Portuguese, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Ukrainian, Urdu, Vietnamese
16-140 DUI / PC Assessment Report (DASA) Word, PDF
16-169 ICW Quarterly Report Word, PDF
16-170 Nursing Assistant Training Program (NATCEP) Curriculum Verification of Requirements - 42 CFR 483.152 and WAC 246-841-400 and 246-841-490 Word, PDF
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration English: Word, PDF
Other languages (PDF): Albanian, Amharic, Arabic, Armenian, Bosnian, Bulgarian, Cambodian, Chinese, Farsi, Finnish, Hindi, Ilocano, Indonesian, Japanese, Korean, Laotian, Mien, Nepali, Oromo, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Tagalog, Thai, Tigrigna, Tongan, Turkish, Ukrainian, Urdu, Vietnamese
16-179 Reference Cover Letter (Children's Administration) English: Word, PDF
Other languages (PDF): Arabic, Korean, Somali, Spanish Word, Spanish, Vietnamese
16-180 CCSP Rights and Responsibilities (Child Care Subsidy Programs) English: PDF
Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Chinese, Farsi, Japanese, Korean, Laotian, Nepali, Oromo, Russian, Somali, Spanish, Swahili, Tigrigna, Vietnamese
16-181 A Guide to In-Home Relative Child Care English: PDF
Other languages (PDF): Arabic, Burmese, Cambodian, Chinese, Dinka, French, Korean, Laotian, Marshallese, Nepali, Nuer, Polish, Punjabi, Russian, Serbo-Croatian, Somali, Spanish, Swahili, Trukese, Tagalog, Ukrainian, Vietnamese
16-182 Guidelines for Completing the ICAP/SIB-R Adaptive Behavior Scale (Children's Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration) Word, PDF
16-192 Intake Cover Letter (Developmental Disabilities Administration) English: Word , PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Tagalog, Vietnamese
16-193 Nurse Aide Registry Inquiry (ADSA) Word , PDF
16-194 DDA Specialty Training Sign-Up Sheet Word , PDF
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative English: Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese
16-197 Assisted Living Facility Policies and Procedures Attestation Word, PDF
16-199 New Case/Resource Manager Technology Training Checklist Word, PDF
16-200 Memo to Provider for Behavior Support, Counseling, and Consultation Services Word, PDF
16-202 5-Day Investigation Report Word, PDF
16-202A Plan of Correction (5-Day Investigation) Word, PDF
16-203 SIS Rating Key English: PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Vietnamese
16-204 Fire Evacuation Plan English: Word, PDF
Other languages (PDF): Arabic, Korean, Spanish Word, Spanish, Vietnamese
16-205 Personal Emergency Plan Information English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
16-213 Verification of Legal Status English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
16-214 Administrative Hearing Docket Cover Sheet Word, PDF
16-220 SOLA Incident Report (DDA) Word, PDF
16-221 Children's Respite in Licensed Staffed Residential/Foster Home Settings PDF
16-222 Accessing Out-of-Home Respite Services PDF
16-223 RHC Visiting Professional Sign-In Record Word, PDF
16-225 Respite Provider Checklist Word, PDF
16-229 Educational Resources for Youth in Foster Care Through DSHS in Washington State or a Tribal Child Welfare Agency PDF
16-230 Children's Residential Services Word, PDF
16-231 Permanency Planning Benefits and Limitations PDF
Other languages (PDF): Spanish
16-232 Medicaid Provider Profile Request Word, PDF
16-233 Mentor Program Referral and Guidelines Word, PDF
16-234 Vulnerable Adult Statement of Rights PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
17-011 Forms and Publications Request
PDF Instructions
Word, PDF
17-041 Request for Records English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
17-041A Request for Children's Administration Records English: Word, PDF
Other languages (PDF): Spanish, Spanish Word
17-063 Authorization English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Mien, Portuguese, Punjabi, Russian, Somali, Spanish, Sudanese, Tigrigna, Trukese, Vietnamese
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion Word, PDF
17-123 Spoken Language Interpreter Service Appointment Record
PDF Instructions
Word, PDF
17-123A Request for Sign Language Interpreter Word, PDF
17-155 Sign Language Interpreter Registration Word, PDF
17-155A Sign Language Interpreter Registration Renewal Word, PDF
17-180 Personal Information Release (Economic Services Administration) Word, PDF
17-194 Request for Mental Health Service Information Word, PDF
17-211 Authorization for SSI Facilitation Records (Economic Services Administration) Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
17-215 DSHS / CA Checklist: Subcontractors Approval Request (Children's Administration Word, PDF
17-221 Legal Sign Language Interpreter Registration Word, PDF
17-223 Request for Assistive Listening Systems (Office of the Deaf and Hard of Hearing) Word, PDF
18-078 Application for Nonassistance Support Enforcement Services English: Word, PDF
Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Cantonese, Chinese, Farsi, French, Hmong Italian, Japanese, Korean, Laotian, Malayalam, Oromo, Portuguese, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Ukrainian, Vietnamese
18-097 Statement of Resources and Expenses English: Word, PDF
Other languages (PDF): Amharic, Armenian, Arabic, Bengali, Burmese, Cambodian, Chinese, Chiu Chow, German, Ilocano, Karen, Korean, Marshallese, Mongolian, Nepali, Oromo, Punjabi, Russian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Turkish, Vietnamese
18-235 Initial payment (Interim Assistance Reimbursement Authorization) English: Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Serbo-Croatian, Somali, Spanish, Tagalog, Vietnamese
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
18-398A Vendor Overpayment Notice English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Farsi, Korean, Laotian, Romanian, Russian, Samoan, Somali, Spanish, Thai, Tigrigna, Ukrainian, Vietnamese
18-399 Social Service Incorrect Payment Computation English: Word, Excel, PDF
Other languages (PDF): Amharic, Arabian, Cambodian, Cantonese, Chinese, Farsi, Hmong, Korean, Laotian, Romanian, Russian, Samoan, Somali, Spanish, Thai, Tigrigna, Ukrainian, Vietnamese
18-400 Foster Parent Reimbursement Claim and Checklist (Children's Administration) English: Word, PDF
Other languages (PDF): Spanish Shana, Spanish,
18-400A Third Party Claim Checklist (Children's Administration) Word, PDF
18-433 Declaration of Support Payments (Division of Child Support) English: Word, PDF
Amharic, Arabic, Burmese, Cambodian, Chinese, Italian, Korean, Laotian, Malayalam, Mien, Mongolian, Oromo, Portuguese, Romanian, Russian, Samoan, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Vietnamese
18-463 New Hire Reporting Methods and Instructions Word, PDF
18-483 Employer Payment Identification Instructions English: Word, PDF
Other languages (PDF): Russian, Spanish
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information English: Word, PDF
Other languages (PDF): Arabic, Punjabi, Russian, Spanish, Vietnamese
18-503 Financial Information Sheet English: Word, PDF
Other languages (PDF): Spanish
18-504 Financial Information Sheet Instructions English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese
18-544 Transmittal of Resident Personal Funds Word, PDF
18-555 Financial Information Sheet English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
18-627 SSP Client Overpayment Notice (State Supplementary Program)(DDA) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word , Spanish, Vietnamese
18-701 Request for Income Information for Purposes of Entering a Child Support Order English: Word, PDF
Other languages (PDF): Spanish,
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation) Word, PDF
19-227 Juvenile Accountability Incentive Block Grant (JAIBG) Financial Report (JRA) Word, PDF
19-228 Juvenile Accountability Incentive Block Grant (JAIBG) Progress Report Word, PDF
19-231A Individual Site Billing Details Excel, PDF
19-231B Program Billing Details Excel, PDF
19-231C Program Billing Details Continuation Excel, PDF
19-232 Academic Cost Excel, PDF
19-232A Academic Cost Continuation Excel, PDF
20-188 Authorized Leave Order (Juvenile Rehabilitation Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
20-190 Personal Property Inventory (Juvenile Rehabilitation) Word, PDF
20-191 Youth Personal Property Transmittal (Juvenile Rehabilitation) Word, PDF
20-198 Sentencing Worksheet (Juvenile Rehabilitation Administration)
PDF Instructions
Word, PDF
20-199 Room and Isolation Confinement Record (Juvenile Rehabilitation) Word, PDF
20-201 Authorized Leave Approval (Juvenile Rehabilitation) Word, PDF
20-205 Plethysmograph Examination Informed Consent (Juvenile Rehabilitation) Word, PDF
20-214 Youth Suicide Precaution Tracking (Juvenile Rehabilitation) Word, PDF
20-215 Law Enforcement Records Request (Juvenile Rehabilitation) Word, PDF
20-216 School Behavior Records Request (Juvenile Rehabilitation) Word, PDF
20-219 Request for Exception to Standards (Juvenile Rehabilitation) Word, PDF
20-220 Supervisory Case Review (Juvenile Rehabilitation) Word, PDF
20-222 Sexual Aggression Vulnerability Youth Assessment (Juvenile Rehabilitation) Word, PDF
20-223 Parent/Guardian Notification (Juvenile Rehabilitation) Word, PDF
20-225 Claim for Damages (Juvenile Rehabilitation) Word, PDF
20-226 Claim for Damages (Juvenile Rehabilitation) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese
20-227 Wanted Person Notice of Cancellation (Juvenile Rehabilitation) Word , PDF
20-228 Conditions of School Involvement School Agreement (JR Community Facility) Word, PDF
20-228A Conditions of School Involvement School Agreement (JR Community Facility) Word, PDF
20-229A Conditions of Employment Employer Agreement (JR Community Facility) Word, PDF
20-229B Conditions of Treatment Provider Agreement (Juvenile Rehabilitation) Word, PDF
20-230 Juvenile Volunteer Project Supervisor Agreement (JR Community Facility) Word, PDF
20-234 Youth Complaint - Appeal Request (Juvenile Rehabilitation) Word, PDF
20-235 SchoolNotification (Juvenile Rehabilitation) Word, PDF
20-236 Notification and Legal Requirements (Juvenile Rehabilitation) English: Word, PDF
20-238 Administrative Report of Incidents (Juvenile Rehabilitation) Word, PDF
20-240 Administrative Reports of Incidents (Parole Programs) (Juvenile Rehabilitation) Word, PDF
20-247 Youth Media Release (Juvenile Rehabilitation) Word, PDF
20-250 Consent for Release to Parent/Guardian/Involved Individual (Juvenile Rehabilitation) Word, PDF
20-253 Polygraph Notification (Juvenile Rehabilitation) Word, PDF
20-256 Integrated Treatment Plan (Juvenile Rehabilitation) Word, PDF
20-258 Stored Property Inventory (Juvenile Rehabilitation) Word, PDF
20-260 Request for Warrant Check on JRA Youth (Juvenile Rehabilitation) Word, PDF
20-271 JRA Integrated Treatment Assessment (Juvenile Justice and Rehabilitation Administration)
PDF Instructions
Word, PDF
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese
20-289 Transition Checklist (Juvenile Justice and Rehabilitation Administration) Word, PDF
21-053 Important Phone Numbers and Emergency Response Information (Adult Family Home) Word, PDF
21-057 SOLA Maintenance/Repair Log (Developmental Disabilities Administration) Word, PDF
21-058 SOLA Monthly Vehicle Checklist (Developmental Disabilities Administration) Word, PDF
21-059 Children's Staffed Residential Quality Assurance Assessment Word, PDF
Other languages (PDF): Spanish, Spanish Word
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment Word, PDF
23-023 Business Assessment Questionnaire Word, PDF
23-027 90 Day Review Checklist For Social Workers Staffed Residential Facilities, Group Care Facilities and Child Foster Homes Word, PDF
23-032 In-State Child Abuse and Neglect Founded Findings Request Word, PDF
23-032A In-State Child Abuse and Neglect Founded Findings Request for Tribes Word, PDF
23-033 Child Abuse and Neglect Information Request Word, PDF
23-034 Alternative Living Financial Report Word, PDF
23-035 CHINS/ARY Report to Juvenile Court Word, PDF
23-036 Child Placing Agency Foster Home Licensing Investigation Word, PDF
23-036a Child Placing Agency Foster Home Licensing Investigation Interviews Word, PDF
23-037 Background Clearance Notification Word, PDF
23-041 Washington State Child Abuse and Neglect Founded Findings Request from Another State Word, PDF
27-043 Contractor Intake Word, PDF
27-051 DSHS / Union Contract Decision Process Word, PDF
27-053 Paternity Information English: Word, PDF
Other languages (PDF): Spanish
27-056 Dependent / Ward of the Court Verification Word, PDF
27-057 Voluntary Placement Services Provider Referral Letter (DDA) Word, PDF
27-059 Finger Print Appointment English: Word, PDF
Other languages (PDF): Arabic, Cambodian, Chinese, Farsi, Korean, Laotian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Thai, Vietnamese
27-063 Voluntary Placement Services For Youth (Age 18-21) Word, PDF
27-076 Mandatory Reporting of Abandonment, Abuse, Neglect, Exploitation, or Financial Exploitation of a Child or Vulnerable Adult (Developmental Disability Administration) Word, PDF
27-081 Employment and Day Program Services Providers: Mandatory Reporting of Abandonment, Abuse, Neglect, Exploitation, or Financial Exploitation of a Child or Vulnerable Adult (Developmental Disability Administration) Word, PDF
27-082 Five Day Notice to Move (Children's Administration) English: Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
27-089 Fingerprint-Based Background Check Notice Word, PDF
Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese
27-093 School Notification (Children's Administration) Word, PDF
27-094 Medical Provider Disclosure Statement (Aging and Long-Term Support Administration) Word, PDF
27-095 Court Report (Children's Administration) Word, PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Tigrigna, Vietnamese
27-100 Authorization to Release Information and Photographs (Office of the Deaf and Hard of Hearing) Word, PDF
27-104 Interstate Compact on Placement of Children (ICPC) Closure Letter (Children's Administration) Word, PDF
27-106 Family Participation Agreement (Children's Administration) Word, PDF
Other languages (PDF): Amharic, Arabic, Bosnian, Cambodian, Chinese, Farsi, Hindi, Hmong, Korean, Laotian, Nepali, Punjabi, Romanian, Russian, Samoan, Somali, Soninke, Spanish Word, Spanish, Swahili, Tagalog, Tigrigna, Vietnamese
27-109 BCCU Applicant Affidavit (Background Check Central Unit) (BCCU) Word, PDF
27-110 Applicant Request for Background Check Information (Children's Administration) Word, PDF
27-111 Continuous Quality Improvement Confidentiality Agreement (Children's Administration) Word, PDF
27-113 Attestation of Individual Provider's Living Situation (Aging and Long-Term Support Administration) Word, PDF
27-115 Privacy Complaint Word, PDF

Back to top of page