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.
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.
Number(desc) | Form Name | File Format | |
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09-520 | Request for Conference Board |
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09-653 | Background Check Authorization | ||
09-693 | Declaration of Lawful Custody |
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09-728 | Washington State Addendum to Box 2 of Part B - Plan Administrator Response | ||
09-741 | Child Support Order Review Request |
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09-989 | Confidentiality Statement - Tribal Employee | ||
09-995 | Companion Home Certification Evaluation (Developmental Disabilities Administration) | ||
10-104B | Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration) | ||
10-210 | Staff Statement of Qualifications | ||
10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | ||
10-231 | Adult Family Home (AFH) Referral Checklist (DDA) | ||
10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
10-234 | Individual with Challenging Support Issues (DDA) | ||
10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
10-244 | Child and Family Engagement Plan (Developmental Disabilities) |
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10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
10-258 | Individual With Possible Community Protection Issues (Developmental Disabilities Administration) | ||
10-268 | Pre-Placement Agreement (Developmental Disabilities Administration) | ||
10-269 | Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration) | ||
10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
10-270 | Assisted Living Facility Admission Agreement(s) Attestation | ||
10-272 | Cross-System Crisis Plan (DDA) | ||
10-277 | Request for Children's Out-of-Home Services (Developmental Disabilities Administration) |