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Electronic DSHS FormsYou 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. 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). 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. 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: To help find a specific form by number or key word, hold down the Ctrl key and type the F key. This will call up the "Find" dialogue box. Enter the number or title word(s) and select "Find Next." |
| Form Number | Form Title | Software |
| 01-110 | Protective Payee Report | Word | ||
| 01-110A | Protective Payee Periodic Social Services Report | Word | ||
| 01-110C | Protective Payee Report Continuation | Word | ||
| 01-192 | Referral for Mental Health/Substance Abuse Assessment (EPSDT) (Healthy Kids) | Shana | ||
| 01-210 | Transmittal of Client Funds from the Protective Payee | Shana | ||
| 02-305 | Service Episode Record (Children's Administration) | Word | ||
| 02-327 | JRA Work Request (Juvenile Rehabilitation Administration) | Word | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory | Word | ||
| 02-528 | Fair Hearing Withdrawal | Word | ||
| PDF Translations: Cambodian, Chinese, Italian, Korean, Laotian, Punjabi, Russian, Samoan, Spanish, Vietnamese | ||||
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (DDD) | Word | ||
| 02-573 | Background check Identification Verification (Office of Deaf and Hard of Hearing) | Word | ||
| 02-574 | Application for Advisory Body Appointment | Word | ||
| 02-578 | TED Monthly Client Contact Report (Division of Vocational Rehabilitation) | Word | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | Word | ||
| 03-077 | Release of All Claims | Word | ||
| 03-133 | Employee/Volunteer Personal Incident Report | Word | ||
| 03-366 | Service Verification and Attendance Record (Children's Administration) | Word | ||
| 03-372 | Process Improvement Request (PIR) (Division of Developmental Disabilities) | Word | ||
| 03-373 | Emergency Information | Word | ||
| 03-374B | DSHS Nondisclosure of Confidential Information for Contractors | Word | ||
| 03-387 | Notice of Privacy Practices for Client Confidential Information | Word | ||
| PDF Translations: Albanian, Amharic, Arabic, Bengali, Bulgarian, Burmese, Cambodian, Chinese, Haitian-Creole/French-Creole, Farsi, French, German, Hindi, Hmong, Hungarian, Ilocano, Indonesian, Italian, Japanese, Korean, Kurdish, Laotian, Oromo, Portuguese, Punjabi, Romanian, Russian, Somali, Serbo-Croatian, Spanish Word, Spanish, Swahili, Tagalog, Thai, Tibetian, Tigrigna, Turkish, Ukrainian, Urdu, Vietnamese | ||||
| 03-387A | Notice of Privacy Practices for Client Confidential Information without Acknowledgement | |||
| 03-389 | Witness Statement | Word | ||
| 03-389A | Assault Benefits Program Witness Statement | Word | ||
| 03-391 | Employee Report of Resident/Client Assault (RCW 72.01.045, RCW 74.04.790) | Word | ||
| 03-394 | Supervisor's Review of Employee Report of Resident/Client Assault | Word | ||
| 03-430 | Alternative Work Schedule Request and Review | Word | ||
| 03-431 | Exchange Time Log | Word | ||
| 04-220 | Family Ancestry Chart (Children's Administration) | Word | ||
| PDF Translations: Spanish Word, Spanish | ||||
| 04-220A | Indian Heritage Questionnaire (Division of Developmental Disabilities | Word | ||
| PDF Translations: Spanish | ||||
| 04-416 | DASA Target Data Elements Assessment/Admission Set-Up | Word | ||
| 04-416A | DASA Target Data Elements Discharge or ADATSA Closure | Word | ||
| 04-417 | DASA Target Detox Short Form | Word | ||
| 04-418 | DASA Target Treatment Activities | Word | ||
| 04-419 | DASA Target Client Support Activities (Non-Treatment) | Word | ||
| 04-420 | DASA Target Facility Staff | Word | ||
| 04-423 | DASA Target Change of Circumstances | Word | ||
| 04-432 | Treatment Plan and Change Report (DASA) | Word | ||
| 04-433 | ADATSA/Adult Assessment | Word | ||
| 04-433B | ADATSA/Adult Assessment ADATSA Treatment Eligibility | Word | ||
| 04-434 | Division of Developmental Disabilities - Tell us how we are doing! | Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 04-436 | DASA Target Group Treatment Activities | Word | ||
| 04-437 | DASA Target Agency Support Activities (Non-Treatment) | Word | ||
| 04-438 | DASA Target Group Support Activities | Word | ||
| 04-442 |
Nursing Home Credit Balance Report
PDF Instructions |
Excel | ||
| 04-443 |
Character, Competence, and Suitability Evaluation for Unsupervised Access to Adult
PDF Instructions |
Word | ||
| 05-013 | Request for Hearing | Word | ||
| PDF Translations: Amharic, Arabic, Bosnian, Cambodian, Chinese, Farsi, Hmong, Korean, Laotian, Polish, Punjabi, Russian, Serbo-Croatian, Somali, Spanish, Tagalog, Tigrigna, Vietnamese | ||||
| 05-180 | Federal Grant Application (Office of Juvenile Justice) | Shana | ||
| 05-180B | State Grant Application (Office of Juvenile Justice) | Shana | ||
| 05-180C | Juvenile Detention Alternatives Initiative Grant Application (Office of Juvenile Justice) | Shana | ||
| 05-180D | Federal Grant Application - CJJC | Shana | ||
| 05-203 | Foster Care Administrative Review (Children's Administration) | Word | ||
| 05-203A | DDD Foster Care Administrative Review | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Samoan, Spanish, Vietnamese | ||||
| 05-210 | Exception Request (DCFS) | Word | ||
| 05-210A | Attachment A Exceptional Cost Foster Care (Children's Administration) | Word | ||
| 05-218 | LIST Examination Application | Word | ||
| 05-220 | Children's Administration Fee Waiver | Shana | ||
| 05-234 | Unit of Local Government (ULG) Application (JRA) | Word | ||
| 05-234A | Unit of Local Government (ULG) Application Continuation (JRA) | Word | ||
| 05-239 | DCFS Social Worker Monthly Progress Report | Word | ||
| 05-246 | Notice of Action Exception to Rule (Home and Community Services) | Word | ||
| PDF Translations: Cambodian, Chinese, Farsi, Hungarian, Japanese, Korean, Kurdish, Laotian, Polish, Punjabi, Russian, Somali, Spanish, Tagalog, Ukrainian, Urdu, Vietnamese | ||||
| 06-110 | Client and Billing Summary | Word | Shana | |
| 06-123 | Nursing Assistant Training and Testing Reimbursement | Word | ||
| 06-124 | Cost of Care Adjustment Request (Division of Developmental Disabilities | Word | ||
| 06-125 | Residential Allowance Request | Word | ||
| 06-126 | MHCP Multiple Premium Payment Adjustment | Shana | ||
| 07-042B | Self-Employment Income Report | Word | ||
| PDF Translations: Cambodian, Chinese, Hmong, Korean, Laotian, Russian, Somali, Spanish, Vietnamese, | ||||
| 07-055 | SSPS Payment Adjustment | Shana | ||
| 07-066 | WCCC Award/Change Letter | Shana | Word | |
| PDF Translations: Arabic, Bulgarian, Burmese, Cambodian, Chinese, French, French-Haitian Creole, Korean, Laotian, Punjabi, Russian, Serbo-Croatian, Somali, Spanish, Swahili, Tigrigna, Vietnamese | ||||
| 07-075 |
In-Home/Relative Provider |
Word | ||
| PDF Translations: Russian, Spanish | ||||
| 07-076 | Request for Information (Working Connections Child Care) | Word | ||
| PDF Translations: Amharic, Arabic, Burmese, Cambodian, Chinese, Hmong, Korean, Japanese, Laotian, Punjabi, Romanian, Russian, Somali, Spanish, Swahili, Tagalog, Vietnamese | ||||
| 07-078 |
Self-Employment Worksheet |
Shana | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 07-079 | Mileage Reimbursement (Childrens Administration) | Shana | Word | |
| 07-081 | Participation Reimbursement Form | Shana | ||
| 07-085 | Planned Action Notice Provider Denial or Termination (DDD) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 07-086 | Notice of Discharge (Division of Developmental Disabilities) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 07-087 | Eligibility Checklist for DDD State Supplementary Payments (SSP) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese | ||||
| 08-225 | Participant Performance Reporting | Shana | ||
| 09-004C | Voluntary Placement Agreement for Child or Youth with Developmental Disabilities | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Spanish, Vietnamese | ||||
| 09-013 |
Vendor Affidavit of Lost, Stolen, or Destroyed Warrant |
Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese | ||||
| 09-048 |
Core Provider Agreement |
Shana | Word | |
| 09-052 | Affidavit of Forged Endorsement | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese | ||||
| 09-097 | Record of Official Actions (Juvenile Rehabilitation Administration) | Word | ||
| 09-341 | Order of Parole Conditions (Juvenile Rehabilitation Administration) | Word | ||
| PDF Translations: Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese | ||||
| 09-453 | Guardianship Petition (Indian Child) | Shana | ||
| 09-474 | Petition for Relinquishment and Termination of Parent - Child Relationship (Indian Child) | Shana | ||
| 09-508 | Waiver of Statute of Limitations Defense | Shana | ||
| PDF Translations: Arabic, Cambodian, Chinese, German, Ilocano, Laotian, Portuguese, Punjabi, Romanian, Russian, Spanish, Tagalog, Vietnamese | ||||
| 09-520 | Request for Conference Board | Shana | ||
| PDF Translations: Arabic, Cambodian, Hebrew, Serbo-Croatian, Somali, Spanish, Russian, Vietnamese | ||||
| 09-536 | Inquiry to Bureau of Indian Affairs (BIA) | Word | ||
| 09-537 | Notice to Non-Federally Recognized or Canadian Indian Tribe or Band RE: Court Hearing | Shana | ||
| 09-539 | Inquiry to Indian Tribe, Band, or Nation | Word | ||
| 09-539A | Inquiry to Indian Tribe, Band, or Nation, and Notice of Incarceration of a Youth | Word | ||
| 09-541 | Notice to Federally Recognized Indian Tribe, Band or Nation | Shana | ||
| 09-542 | Notice of Intervention and Request for Continuance - Indian Tribe | Shana | ||
| 09-543 | Notice to Parent/Indian Custodian | Shana | ||
| 09-545 | Notice to Bureau of Indian Affairs | Shana | ||
| 09-547 | Motion and Order to Transfer Jurisdiction to Tribal Court | Word | ||
| 09-548 | Motion and Order for the Tribal Court to Accept Jurisdiction Under 25 U.S.C. 1911(b) | Word | ||
| 09-559 | Power of Attorney | Shana | ||
| 09-653 | Background Authorization | Word | ||
| PDF Translations: Amharic</ |