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.

Choose search option and begin typing the form #
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Numbersort descending Form Name File Format
01-110 Protective Payee Report
01-110A Protective Payee Periodic Social Services Report
01-110C Protective Payee Report Continuation
01-210 Transmittal of Client Funds from the Protective Payee
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
02-528 Fair Hearing Withdrawal
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
02-573 Background check Identification Verification (Office of Deaf and Hard of Hearing)
02-578 TED Monthly Client Contact Report (Office of Deaf and Hard of Hearing)
02-586 Temporary Employment Hours Tracking Log
02-587 CLIP/CSO Communication
02-589 Companion Home Outside Employment Notification (Developmental Disabilities Administration)
02-592 Application for Approval of Interpreter Continuing Education Activity
02-611 Statement of Understanding: Mid-Certification Review
03-076 Employee Personal Property Damage/Loss Claim
03-077 Release of All Claims
03-133 Injury and Illness Incident Report
03-133A Supervisor's Review of Injury / Illness Incident
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
03-374E Confidential Information, Fraud and Abuse
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-391 Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-478 Children's Administration Travel Authorization
04-220 Family Ancestry Chart (Children's Administration)
04-220A Indian Heritage Questionnaire
04-416 DBHR Target Data Elements Assessment/Admission Setup
04-416A DBHR Target Data Elements Discharge
04-417 DBHR Target Detox Short Form
04-418 DBHR Target Treatment Activities
04-419 DBHR Target Client Support Activities (Non-Treatment)
04-420 DBHR Target Agency Staff
04-423 DBHR Target Change of Circumstances
04-432 Treatment Plan and Change Report (DASA)
04-436 DBHR Target Group Treatment Activities
04-437 DBHR Target Agency Support Activities (Non-Treatment)
04-438 DBHR Target Group Support Activities
04-442 Nursing Home Credit Balance Report
04-443 Character, Competence, and Suitability Evaluation for Unsupervised Access to Adults
04-444 DBHR Target Data Elements Waiting List - First Contact
05-010 Rule Exception Request
05-013 Request for Hearing
05-180 Federal Grant Application (Washington State Partnership Council on Juvenile Justice)
05-180B State Grant Application (Washington State Partnership Council on Juvenile Justice)
05-180C Juvenile Detention Alternatives Initiative Grant Application (Washington State Partnership Council on Juvenile Justice)
05-180E State Gang Prevention and Intervention Application (Washington State Partnership Council on Juvenile Justice)
05-180F Federal Grant Application - B (Washington State Partnership Council on Juvenile Justice)
05-210 Exceptional Cost Request (ECR) (Children's Administration)
05-210A Attachment A Exceptional Cost Foster Care (Children's Administration)
05-218 LIST Examination Application
05-234 Unit of Local Government (ULG) Application (JRA)
05-234A Unit of Local Government (ULG) Application Continuation (JRA)
05-246 Notice of Action Exception to Rule
06-123 Nursing Assistant Training and Testing Reimbursement
06-124 Cost of Care Adjustment Request (Developmental Disabilities)
06-125 Residential Allowance Request (Developmental Disabilities)
06-159 Psychologist and Sex Offender Treatment Provider Invoice
06-160 Adoption Support Monthly Counseling Billing
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
06-165 Extended Foster Care Denial Letter (Children's Administration)
06-166 Individual Training Plan (Division of Licensed Resources, Children's Administration
06-168 Enhanced Services Facility Change in Licensed Bed Capacity - Increase
06-169 Enhanced Services Facility Change in Licensed Bed Capacity - Decrease
06-170 Funding and Expenditure Data
07-066 CCSP Award/Change Letter
07-075 In-Home/Relative Provider
07-076 Request for Information (Child Care Subsidy Programs)
07-081 Participation Reimbursement
07-090 Caregiver Monthly Mileage
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
07-098 Self Employment Monthly Sales and Expense Worksheet
07-101 School-Aged Children Change of Circumstances (Economic Services Administration)
07-103 Participant Reimbursement
07-103A Participant Reimbursement with Interpreter Declaration
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
09-052 Affidavit of Forged Endorsement
09-097 Record of Official Actions (Juvenile Rehabilitation Administration)
09-341 Order of Parole Conditions (Juvenile Rehabilitation Administration)
09-508 Waiver of Statute of Limitations
09-520 Request for Conference Board
09-536 Inquiry to Bureau of Indian Affairs (BIA)
09-537 Notice to Non-Federally Recognized or Canadian Indian Tribe or Band RE: Court Hearing
09-539 Inquiry to Indian Tribe, Band, or Nation
09-539A Inquiry to Indian Tribe, Band, or Nation, and Notice of Incarceration of a Youth
09-653 Background Authorization
09-705 Order of Continued Detention or Release (Juvenile Rehabilitation)
09-706 Parole Revocation Petition (Juvenile Rehabilitation Administration)
09-713 Order Denying Parole Revocation Petition (Juvenile Rehabilitation)
09-714 Order Revoking Parole (Juvenile Rehabilitation Administration)
09-746 Notice of Sex/Kidnapping Offender Registration Requirements
09-746A DSHS Sex / Kidnapping Offender Preregistration
09-747 Notification of Release (Juvenile Rehabilitation Administration)
09-747A Notification of Sex Offender Release (Juvenile Rehabilitation)
09-760 Motion, Declaration of Child's Return from Voluntary Foster Care Placement, and Order of Dismissal
09-761 Indian Identity Request
09-762A Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Developmental Disabilities Administration)
09-765 Declaration of Adoption Facilitator - Indian Child
09-777 Indian Child: Compliance Checklist
09-808 JRA Notice and Finding of Financial Responsibility
09-837 Disclosure of Confidential HIV/AIDS Information
09-876 Permanency Planning Findings and Order (Child With a Developmental Disability)
09-877 Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability)
09-878 Order Approving Continued Out-of-Home Care (Child With a Developmental Disability)
09-892 Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Developmental Disabilities Administration)
09-893 Periodic Review of Individual Service Plan (DDA)
09-961 Nursing Assistant Training Program (NATCEP) Declaration of the Program Director
09-966 Authorization to Release Information to the Court (Children's Administration)
09-979 Marital History
09-995 Companion Home Contract Evaluation (DDA)
09-997 Adoption Support Worksheet
09-998 Application For The Adoption Support Program and/or Reimbursement of Adoption Finalization Costs
10-016 Certification for License of Foster Home
10-017 Termination of Foster Home License
10-043 Family Home Study
10-061 Child's Registration
10-083 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Assessment
10-104B Service Verification/Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-114 Adoption Data Card
10-161 Mental Health Evaluation and Treatment Application for Certification
10-166A Behavioral Rehabilitation Services Referral
10-182 Home Study File Checklist (Children's Administration)
10-182A Unlicensed File Checklist
10-183 Foster Home Inspection Checklist (Children's Administration)
10-209 Application for Program Certification
10-210 Staff Statement of Qualifications
10-214 Preauthorization for Services (Children's Administration)
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
10-231 Adult Family Home (AFH) Placement Checklist (DDA)
10-232 Provider Referral Letter For Supported Living/Group Home Providers
10-232A Provider Referral Letter
10-234 Individual with Challenging Support Issues (DDA)
10-237 Notice of Transfer or Discharge
10-238 Request for an Administrative Hearing (Residential Care Services)
10-241 Report to Protective Services (Juvenile Rehabilitation)
10-244 Shared Parenting Plan (Developmental Disabilities)
10-246 Permanency Plan
10-248 Compliance Agreement
10-248A Compliance Agreement Continuation
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-257 Voluntary Placement Services Foster Care Medical Team (FCMT) Communication
10-258 Individual with Community Protection Issues (DDA)
10-261 Foster Care Rate Assessment
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-269 Alternative Living Services Plan and Provider Report (Developmental Disabilities))
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-272 Cross-System Crisis Plan (DDA)
10-276 WTRS Consumer Response (Office of Deaf and Hard of Hearing)
10-277 Request for Children's Residential Services
10-290 Policy Agreement (Children's Administration)
10-294 Mandatory Report to Law Enforcement
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
10-326 Assisted Living Facility Admission Agreement(s) Attestation
10-327 Residential Staff Schedule Reporting
10-328 Residential Site Approval Request
10-329 Informed Consent for ICAP
10-330 Request For Legal Advice
10-331 DDA Mortality Review Part 1. Provider Report
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-335 Dyskinesia Identification System: DISCUS Rating (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
10-348 Information Checklist (DDA)
10-349 Comprehensive Review Tool
10-351 Disclosure of Services (ADSA Boarding Homes)
10-353 Documentation Request for Medical or Disability Condition
10-354 Family Home Study Application (Children's Administration)
10-356 Application for Peer Counselor
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-360 Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B
10-361 Assisted Living Facility Resident List - Attachment C
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-376 Password Change/Confirmation Request Nursing Home Facility Log-in
10-377 Notification of Age Four (4) Eligibility Expiration-
10-378 Notification of Age Ten (10) Eligibility Expiration
10-382 Naturalization Services Pre-Screening
10-389 Approved Sleeping Room List For Assisted Living Facilities
10-389A Additional Rooms List For Assisted Living Facilities
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-395 Intensive Family Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary
10-396 SSI Letter (DDA)
10-400 Information Request Letter
10-402 Child Placing Agency Referral
10-403 Abuse/Neglect Reporting Requirement Information
10-405 Foster Home Re-Assessment
10-406 Employed Foster Parent Child Care Plan
10-410 Adult Family Home License Application
10-411 Consumer Response: Do Not Hang Up Complaint
10-412 Adult Family Home License Relinquishment Letter
10-413 Application For Contract For Currently Licensed Boarding Home
10-416 Foster Home Monitoring Visit
10-417 Adult Family Home Caregiver Experience Attestation (CEA) Form A for Applicants for Licensure
10-418 Fostering Well-Being Care Coordination Referral
10-419 Licensing and Safety Supervision Plan For Site Specific Conditions
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-425 Respite Provider Reference Questionnaire
10-426 Respite Care Applicant Letter
10-427 School District Communication
10-428 Caregiver Support Plan (Children's Administration)
10-432 Extended Foster Care Program Participant Agreement
10-436 Foster Care License Renewal Notice
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-438 Long-Term Care Partnership (LTCP) Asset Designation
10-441 Individuals: Subscription and Directory (Office of the Deaf and Hard of Hearing)
10-441 Large Print Individuals: Subscription and Directory - Large Print (Office of the Deaf and Hard of Hearing)
10-442 Goal Setting and Action Planning Worksheet
10-443 Organizations: Subscription and Directory (Office of the Deaf and Hard of Hearing)
10-444 Relative Caregiver / Suitable Other Placement Fact Sheet and Home Study Checklist
10-448 Nurse Delegation Contract Monitoring Chart Audit
10-450 Statement of Qualifications and Verification of Issues Discussed (Children's Administration)
10-453 Household Safety Inspection for Unlicensed Placements
10-454 Children's Administration Caregiver Authorization
10-455 Medical Log (Children's Administration)
10-456 Mental Health Treatment Options
10-458 Home Study Referral Notice (Children's Administration)
10-459 Courtesy Supervision Referral Checklist
10-460 Treehouse Educational Advocacy Referral (Children's Administration)
10-462 User Application and Agreement (Children's Administration)
10-463 FamLink Data Access Request / Change (Children's Administration)
10-464 FamLink Access Application and Agreement (Children's Administration)
10-466 Early Family Support Services Referral (Children's Administration)
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-469 Notice to Clients Who Employ An Individual Provider (Home and Community Services)
10-470 Children's Intensive In-Home Behavioral Support (CIIBS) Service Request (Developmental Disabilities Administration)
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-474 FAR Family Assessment (Children's Administration)
10-475 Early Intervention Program (EIP) Exit Summary (Children's Administration)
10-476 EFSS 90 Day Review (Early Family Support Services)
10-478 Early Family Support Services (EIP) Exit Summary (Children's Administration)
10-479 Early Intervention Program (EIP) 90 Day Review (Children's Administration)
10-480 Comprehensive Family Evaluation (Children's Administration)
10-481 Health Action Plan (HAP)
10-484 Youth Run Prevention Plan (Children's Administration)
10-485 Treehouse Education Advocacy Program Case Activity Report (Children's Administration)
10-486 Assisted Living Facility Food Service Observations - Attachment P
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-488 Extended Foster Care Program Consent
10-489 Confidential Health Information Consent Agreement
10-490 Child Specific Contract Rate Proposal
10-491 Statement of Children’s Administration (CA) Worker
10-492 Service Referral (Children's Administration)
10-496 Family Assessment Response: Referral for Community Resources (Children's Administration)
10-497 Continuous Quality Improvement (CQI) Action Plan
10-498 Completion of your Family Assessment Response (FAR) Case (Children's Administration)
10-499 Education Plan (Children's Administration)
10-500 Acknowledgement of Child(ren)’s Adoptive File Provided to Adoptive Family (Children's Administration)
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-502 Service Intervention Plan
10-503 Limitation Extension Evaluation
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
10-506 Limitation Extension Request Checklist
10-507 Orientation Sign-In Sheet
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-509 Pediatric Symptoms Checklist (PSC-17)
10-510 Comprehensive Review: BRS / Contracts Program Review
10-511 Comprehensive Review: DLR Program Review
10-512 Comprehensive Review: BRS Contractor Client File
10-513 Comprehensive Review: DLR Client File
10-514 Comprehensive Review: Personnel Files
10-515 CA Worker Questionnaire
10-516 Youth Interview
10-517 Staff Interview
10-518 Foster Parent Interview
10-519 Incident Report Review
10-520 Comprehensive Review Final Report
10-521 Comprehensive Review: Compliance Agreement
10-522 Comprehensive Review: Immediate Action Plan Compliance Agreement
10-523 Orientation and Development Progress Report
10-524 Session 1 Practice Record
10-525 Session 2 Practice Record
10-526 Session 3 Practice Record
10-527 Preparation for Compliance Survey
10-528 Observational Surveys
10-529 Session 1 Participatory Survey
10-530 Session 2 Participatory Survey
10-531 Session 3 Participatory Survey
10-532 Team Coordinator Survey
10-533 First Compliance Survey Results
10-534 Second Compliance Survey Results
10-535 Enhanced Services Facility Application
10-537 Interstate Compact On Placement of Children (ICPC) Parent Home Study Information
10-539 Reference Questionnaire for Parent Home Study
10-540 Project SafeCare Monthly Summary
10-541 Comprehensive Review: DLR Foster Home File
10-542 Refugee Cash Assistance (RCA) Employment Services Referral
10-543 Clone of Refugee Cash Assistance (RCA) Voluntary Employment Services Referral
10-545 Family Feedback Questionnaire
10-546 Adoption Archive Request for Non-Identifying Information
11-019 Vocational Information (Division of Vocational Rehabilitation)
11-022 Application for Vocational Rehabilitation Services
11-030 Service Delivery Outcome Report
11-045 Work Experience (WEX) Referral (Food Stamp Employment and Training)
11-046 Work Experience (WEX) Agreement (Food Stamp Employment and Training)
11-055 Acknowledgement of My Responsibilities As The Employer of My Individual Providers
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
11-066 Assistive Listening Device(s) (ALD) Sign-Out Register (Office of Deaf and Hard of Hearing)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-068 DVR Internship Application (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-072 DVR Internship Evaluation (Division of Vocational Rehabilitation)
11-078 Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation)
11-079 Centers for Independent Living (CILs) Title VII, Part B, Contract Annual Report
11-080 Centers for Independent Living (CILs) Title VII, Part B Monthly Report
11-084 Employees Approved to Provide IL Services and Type of Service Provided (Division of Vocational Rehabilitation)
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing)
11-094 User Agreement (Office of the Deaf and Hard of Hearing)
11-094 Large Print User Agreement (Large Print) (Office of the Deaf and Hard of Hearing)
11-095 National Deaf-Blind Equipment Distribution Program (NDBEDP) Client Complaint
11-097 Service Delivery Outcome Report
12-006 Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program
12-195 Disqualification Consent Agreement
12-206 Application for Disaster Food Stamp Assistance
12-207 Application for Disaster Cash Assistance
13-001 Applicant Medical Report - Confidential
13-021 Physical Evaluation
13-041 Child’s Medical and Family Background Report
13-433 Transfer/Discharge Health Summary (Juvenile Rehabilitation)
13-585A Range of Joint Motion Evaluation Chart
13-628 Involuntary Treatment Act Patient Claim Information
13-645 Adult Family Home Injuries and Accidents Log
13-677 Naltrexone Authorization
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678A Nurse Delegation: PRN Medication
13-678B Nurse Delegation: Assumption of Delegation
13-680 Nurse Delegation: Rescinding Delegation
13-681 Nurse Delegation: Change in Medical Orders
13-690 Medical Services Authorization (Juvenile Rehabilitation)
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
13-712 Medicaid Personal Care Client RSN Transmittal
13-713 Fast Track Service Agreement
13-720 Suboxone Authorization
13-734 Documentation of First Use of Medicaid Benefits (DDA)
13-738 DDA / CA Request to Cost Share
13-749 Campral Authorization (Division of Behavioral Health and Recovery)
13-750 Suboxone Exemption Request (Division of Behavioral Health and Recovery)
13-776 Nursing Services Referral
13-784 Nursing Services Assessment
13-791 Vivitrol IM Physician Prior Authorization
13-830 ICF/ID Admissions Review Team Checklist
13-851 Psychiatric Referral Summary
13-851A Psychoactive Medication Treatment Plan
13-851C Psychoactive Medication Treatment Plan Annual Continuation of Medication
13-865 Psychological/Psychiatric Evaluation
13-893 Nurse Delegation: Request For Additional Units
13-899 Review of Medical Evidence
13-901 Buprenorphine Authorization for Pregnancy
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
13-905 Autistic Disorder Confirmation (Developmental Disability Administration)
13-906 Therapy Assessment Bed Rails or Side Rails (Home and Community Services)
14-001 Application for Cash or Food Assistance
14-012 Consent
14-050 Statement of Health, Education, and Employment
14-057 Child Support Referral
14-057B Noncustodial Parent Child Support Enforcement Application
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-078 Eligibility Review
14-084 Financial/Social Services Communications
14-113 Client Rights and Responsibilities
14-118A ADATSA Incapacity Decision/Disposition
14-144A Medical Disability Decision
14-151 Request for DDA Eligibility Determination
14-155 Senior Citizens Service Application
14-162 Veteran's Referral
14-222 Statement of Collateral Information
14-222 SUMMARY Statement of Collateral Information Summary
14-223 Statement from School
14-224 Statement from Landlord/Manager
14-225 Acknowledgement of Services
14-238 Client Income Report
14-245 Education List Checklist (Juvenile Rehabilitation)
14-251 Revocable Burial Fund Provision for SSI Related Healthcare
14-251A Irrevocable Burial Fund Provision for SSI Related Healthcare
14-252 Employment Verification
14-264 Application for Telecommunications Equipment
14-281 Source of Funds Application for Child in Placement
14-293 Title IVE Initial Eligibility Determinations: Income Calculation Worksheet (Children's Administration)
14-299 ADATSA / Adult Assessment Referral
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-310 Client Status Change Report
14-311A Assessment Center Summary for TANF
14-319 Title IVE Initial Eligibility Determination for an Adoption Support Application (CA)
14-332 Disability Assessment
14-338 Level II: Initial Psychiatric Evaluation Summary Information
14-339 Level II: Follow-Up or Significant Change Psychiatric Evaluation Summary Information
14-349 Protective Payee Assessment
14-369 Nursing Assistant Training Program (NATCEP) Instructional Staff Applications
14-370 Nursing Assistant Training Program (NATCEP) Application for Program Director
14-371 Nursing Assistant Training Program (NATCEP) Application for Approval
14-381 WorkFirst Individual Responsibility Plan
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
14-402 Notice to Parents (WorkFirst)
14-413 Level II: Invalidation Statement, Statement and Criteria of Non-Completion
14-413A Level II: Invalidation Statement: Documentation for Interrupted Evaluation
14-416 Eligibility Review for Long Term Care Benefits
14-417 Child Care Subsidy Programs (CCSP) Application
14-417A In-Home/Relative Pending Letter (Child Care Subsidy Program)
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-427 Teen Parent Living Assessment
14-431 Medical / Dental Services Authorization
14-432 Direct Deposit Enrollment
14-434 Title IV-E Requirements for Out of State Foster Care Payments (Children's Administration)
14-435 Provider Employment Eligibility Verification (Children's Administration)
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-438 Stop Work
14-439 WASHCAP Application
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
14-443 Financial / Social Services Communication
14-444 Child Health and Education Tracking Screening Report (Children's Administration)
14-445 Nursing Assistant Training Program (NATCEP) Application for Renewal (Aging and Long-Term Support Administration)
14-445 PILOT Nursing Assistant Training Program (NATCEP) Application for Renewal
14-446 Declaration of Financial Status (Children's Administration)
14-448 ADATSA Request for Exception to Contract
14-449 Unmet Need Breakdown
14-452 Financial Worksheet (Children's Administration)
14-453 Protective Payee Decision
14-454 Estate Recovery: Repaying the State for Medical and Long Term Care (LTC)
14-459 Eligible Conditions Specific to Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-463 Waiver Transportation Record (DDA)
14-465 Sources For Eligibility Information (DDA)
14-467 Mid-Certification Review
14-473 ICAP Letter
14-474 Shared Planning Meeting
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Treatment Verification Request
14-479 DASA Target Data Element - Gain Short Screening Setup
14-484 Nurse Delegation: Nursing Visit
14-485 GAIN-SS (Mental Health)
14-489 SSIF Introduction Letter
14-491 NSA Representative Checklist For AAG Authorization
14-492 Assessment Meeting Wrap-up
14-493 Requirement to Identify a Representative
14-495 Naturalization Letter
14-501 Community Resource Declaration
14-502 SSI Hearing Denial
14-503 Interim Assistance Reimbursement Agreement Cover
14-505 Application for Deaf-Blind Communicator (DBC)
14-510 Respite Provider Policy Agreement
14-512 Application For Respite Provider Approval
14-513 Respite Care Provider Cover Letter
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-517 DSHS Letter Requesting Non Work SSN
14-520 Your DSHS Cash or Food Assistance Benefits
14-521 Your Rights (Home and Community Services)
14-522 Chemical Dependency Good Cause Letter
14-525 Incapacity Review for Medical Care Services
14-526 Chemical Dependency Treatment Verification Request
14-527 Medical Care Services Case Plan
14-528 Chemical Dependency NonCooperation
14-529 Chemical Dependency Requirement
14-530 Disability Review
14-531 Education and Training Voucher (ETV) Program andPassport to College Promise Scholarship 2015 - 2016 Application
14-532 Authorized Representative
14-533 National Deaf-Blind Equipment Distribution Program Application 
14-533 Large Print National Deaf-Blind Equipment Distribution Program Application (Large Print) 
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
15-031 Notice of Action - Adult Residential Services
15-051 Individual Provider Time Sheet
15-092 Interstate Compact On Placement of Children (ICPC) Placement Request
15-093 Interstate Compact on the Placement of Children Report on Child's Placement Date or Change of Placement - 100B
15-184 Volunteer Chore Service Referral
15-209C Visiting Plan
15-215 AFH Quality Improvement Visit Assessment
15-243 Social Services Case Reading Guide
15-245 LEP Client Service Record (Limited English Proficient)
15-247 Working Connections Child Care (WCCC) Termination Letter
15-247A Working Connections Child Care (WCCC) Denial Notice
15-252 DRW Access Request Checklist
15-258 Safety Assessment
15-259 Safety Plan
15-260 Parent Information Sheet For Shared Planning Meetings and Staffings
15-266 CPT Staffing Recommendations
15-268 CPT Case Presentation Summary
15-274 Assistance Available Schedule (DDA)
15-276 Personal Information (Children's Administration)
15-280 Unlicensed Caregiver Placement Checklist (Children's Administration)
15-281 Placement Agreement (Children's Administration)
15-282A Request for Enrollment in Division of Developmental Disabilities (DDD) Home and Community Based Services (HCBS) Waiver or Request to Change From One DDD HCBS Waiver to Another
15-286 Reference Questionnaire
15-290 Notification of Annual Assessment Review
15-291 Client Notification of Annual Assessment Meeting
15-295 Waiver Individual Support Plan Meeting Survey
15-300 Child Information and Placement Referral
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-308 Missing Child Staffing
15-309 Returning Child De-Briefing
15-313 Caregiver's Report to the Court
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-322 Long Term Care Agreement For Foster Parents or Relative Caregivers
15-323 Checklist For Approval Long Term Care Agreement For Foster Parents or Relative Caregivers
15-324 Guardianship Approval Checklist
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-342 Notice of Exception to Rule Decision
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-356 DDA Community Protection Program Chaperone Agreement
15-357 Residential Services Opening Description
15-358 Client Referral Information
15-359 Child's Physical Description
15-360 Residential Services Capacity Profile
15-361 Individual and Family Services Program Request List - No Response
15-362 Concurrent TANF Benefits / Family Reunification Notice of Removal from TANF Home (Children's Administration)
15-363 Parent / Child / Sibling Visit Service Referral
15-363B Provider Notification of Visit / Transport Schedule Initial Intake Screening Report
15-365 Community Protection Treatment Worksheet Quarterly Review
15-366 Change of Address
15-367 Administrative Review Request For Crime and/or Negative Action
15-368 Educational and Training Voucher (ETV) Program Participation Agreement
15-369 Educational and Training Voucher (ETV)Program Renewal Application
15-370 Education and Training Voucher (ETV) Program Payment Request
15-372 Enumeration Referral
15-374 Physician Certification For Child/Youth With Developmental Disabilities to Maintain Their Permanent Residence
15-375 Home Study Referral for Contracted Services
15-376 Skin Observation Protocols
15-377 Education and Training Voucher (ETV) Program Dual Credit Application
15-379 Vendor Request for Staff Add-On (DDA)
15-380 Individual and Family Services Assessment Worksheet
15-381 Respite Assessment Worksheet
15-382 Positive Behavior Support Plan (PBSP)
15-383 Functional Behavioral Assessment (FA)
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
15-387 Respite Application - Licensed Staffed Residential/Foster Home
15-388 Alternative Living Review and Evaluation
15-389 Certified Community Residential Services and Support Application
15-398 Medically Intensive Children's Program (MICP) Application
15-402 Notice to Foreign Consulate of Child Protection Proceedings
15-411 Licensing Waiver/Administrative Approval
15-417 Transition Plan for Youth Exiting Care
15-419 Refusal of Services Statement
15-420 Request For ICF/ID Admission
15-422 No Paid Services Group
15-424 Staffed Residential Cost of Care Adjustment Request
15-428 Protective Action(s) Plan (Children's Administration)
15-430 Seasonal Child Care (SCC) Termination Notice
15-430A Seasonal Child Care (SCC) Denial Notice
15-431 Extended Foster Care Services Voluntary Placement Agreement
15-432 Educational Liaison's Report to the Court
15-433 Incomplete Application
15-434 On-Going Mental Health (OMH) Screening Report
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
15-436 Request for Adult Family Home Application Fee Waiver
15-437 Staff Orientation Checklist
15-438 Inspection (Assisted Living Facility)
15-439 Follow-up / Monitoring Inspection (Assisted Living Facility)
15-440 Complaint Investigation (Assisted Living Facility)
15-441 Team Coordinator (Assisted Living Facility)
15-444 Re-Inspection
15-445 Follow-up / Monitoring Inspection
15-446 Complaint Investigation
15-447 Exception to Rule (ETR) to Room Requirements (Home and Community Services)
15-448 Visit Report: Parent - Child Visit
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
15-450 Child Specific Caregiver Notification
15-451 Missed and No Show Report: Parent - Child Visit
15-452 Sibling Visit Report
15-453 Unsupervised / Transportation Only Report
15-454 Parent - Child Visit (PCV) Incident Report
15-455 Certificate of Exemption
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
16-107 Noncustodial Parent's Rights and Responsibilities
16-170 Nursing Assistant Training Program (NATCEP) Curriculum Verification of Requirements - 42 CFR 483.152 and WAC 246-841-400 and 246-841-490
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration
16-179 Reference Cover Letter (Children's Administration)
16-180 CCSP Rights and Responsibilities (Child Care Subsidy Programs)
16-181 A Guide to In-Home Relative Child Care
16-182 Guidelines for Completing the ICAP/SIB-R Adaptive Behavior Scale (Children's Administration)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-192 Intake Cover Letter (Developmental Disabilities Administration)
16-193 Nurse Aide Registry Inquiry (ADSA)
16-194 DDA Specialty Training Sign-Up Sheet
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-197 Assisted Living Facility Policies and Procedures Attestation
16-199 New Case/Resource Manager Technology Training Checklist
16-200 Memo to Provider for Behavior Support, Counseling, and Consultation Services
16-202 5-Day Investigation Report
16-202A Plan of Correction (5-Day Investigation)
16-203 SIS Rating Key
16-204 Fire Evacuation Plan
16-205 Personal Emergency Plan Information
16-213 Verification of Legal Status
16-217 Interstate Compact On Placement of Children (ICPC) Quarterly Supervision Report
16-220 SOLA Incident Report (DDA)
16-221 Children's Respite in Licensed Staffed Residential/Foster Home Settings
16-222 Accessing Out-of-Home Respite Services
16-223 RHC Visiting Professional Sign-In Record
16-225 Respite Provider Checklist
16-229 Educational Resources for Youth in Foster Care Through DSHS in Washington State or a Tribal Child Welfare Agency
16-230 Children's Residential Services
16-231 Permanency Planning Benefits and Limitations
16-232 Medicaid Provider Profile Request
16-234 Vulnerable Adult Statement of Rights
16-235 Photo Release
17-011 Forms and Publications Request
17-041 Request for Records
17-041A Request for Children's Administration Records
17-063 Authorization
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-123 Spoken Language Interpreter Service Appointment Record
17-123A Request for Sign Language Interpreter
17-155 Sign Language Interpreter Registration
17-155A Sign Language Interpreter Registration Renewal
17-180 Personal Information Release (Economic Services Administration)
17-194 Request for Mental Health Service Information
17-208 PRISM Registration
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
17-215 DSHS / CA Checklist: Subcontractors Approval Request (Children's Administration
17-221 Legal Sign Language Interpreter Registration
17-223 Request for Assistive Listening Systems
17-226 AAA DSHS / HCS Systems Access Request
17-227 DSHS / HCS Systems Access Request
18-078 Application for Nonassistance Support Enforcement Services