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.

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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Number(desc) Form Name File Format
01-110 Protective Payee Report
01-110A Protective Payee Periodic Social Services Report
01-110C Protective Payee Report Continuation
01-205 Workfare Activity Report
01-210 Transmittal of Client Funds from the Protective Payee
01-212 ALTSA Nurse Delegation Referral and Communication Case / Resource Manager's Request
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
02-589 Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration)
02-592 Application for Approval of Interpreter Continuing Education Activity
02-611 Statement of Understanding: Mid-Certification Review
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
02-634 Additional Information Needed for ILP TANF
03-076 Employee Personal Property Damage/Loss Claim
03-077 Release of All Claims
03-133 Safety Incident / Near Miss Report
03-133A Supervisor's Review of Safety Incident / Near Miss Report
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
03-374D ESA Non-Dislcosure of Confidential Information Agreement - 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
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-494 Medication Administration Competency Assessment Tool
04-220 Family Ancestry Chart (Children's Administration)
04-220A Indian Heritage Questionnaire (Developmental Disabilities Administration)
04-442 Nursing Home Credit Balance Report
04-446 Tell Us How We are Doing! (Division of Child Support)
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
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)
05-180F Federal Grant Application - B (Washington State Partnership Council on Juvenile Justice)
05-210 DCFS Administrative Approval Request (Children's Administration)
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-249 Adult Residential Care Services Notice of a Change
05-251 Rule Change Comments (Residential Care Services)
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
05-254 Federal Subminimum Wage Certificate Holder
05-255 Medicaid Transformation Project Demonstration Notice of Action Exception to Rule
05-256 Notice of Action Exception to Rule for AFH Daily Rates
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-261 Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment)
05-262 Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-263 Long Term Care Survey Process (LTCSP) Self-Asssessment Skill Building Tool
06-123 Nursing Assistant Training and Testing Reimbursement
06-124 Cost of Care Adjustment Request (Developmental Disabilities)
06-125 Residential Allowance Request (Developmental Disabilities Administration)
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)
06-168 AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services)
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
06-170 Funding and Expenditure Data
06-171 Funding and Expenditure Data (Tribal)
06-172 Domestic Violence Prevention Account
06-173 Medical Evidence Reimbursement
06-174 Enhanced Rate Proposal
06-175 Individual Provider (IP) Travel Time Request
06-176 ALF Change in Licensed Resident Bed Capacity or Use of Rooms
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
06-179 Education and Training Voucher (ETV) Program Spending Plan (Children's Administration)
06-180 Nursing Services Activity Report for HCA
06-181 Nursing Services Activity Report for AAAs
06-182 Public Records Customer Experience Survey
07-042B Self-Employment Income Report
07-076 CCSP 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
07-103 Participant Reimbursement
07-103A Participant Reimbursement with Interpreter Declaration
07-104 Financial Communication to Social Services
07-105 CCSP Authorization Letter (Child Care Subsidy Program)
07-106 CCSP Eligibility Letter (Child Care Subsidy Program)
07-106A CCSP Eligibility Waitlist Letter (Child Care Subsidy Programs)
07-106B CCSP Eligibility Letter Waitlist Space Available (Child Care Subsidy Programs)
07-106C CCSP Eligibility Letter - Special Assistance for Families Experiencing Homelessness (Child Care Subsidy Program)
07-106D Child Welfare Continuing Child Care (CWCCC) Eligibility Letter
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
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
09-054 Waiver of Notice of Further Hearing (Children's Administration)
09-097 Record of Official Actions (Juvenile Rehabilitation Administration)
09-280B Petition for Modification - Administrative Order
09-341 Order of Parole Conditions (Juvenile Rehabilitation Administration)
09-415 Authorization for Expenditure (Non-Employee)
09-508 Waiver of Statute of Limitations
09-520 Request for Conference Board
09-539 Inquiry to Indian Tribe
09-539A Indian Heritage Questionnaire and Notice to an Indian Tribe, Nation or Band of Youth Committed to JR
09-653 Background Check Authorization
09-693 Declaration of Lawful Custody
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)
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
09-741 Child Support Order Review Request
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)
09-761 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)
09-808 JRA Notice and Finding of Financial Responsibility
09-809 WorkFirst Word Experience (WEX) Referral
09-810 WorkFirst Word Experience (WEX) Agreement
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)
09-966 Authorization to Release Information to the Court (Children's Administration)
09-979 Marital History
09-989 Confidentiality Statement - Tribal Employee
09-995 Companion Home Evaluation and Review (Developmental Disabilities Administration)
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
10-082 Adoption Support Agreement Review
10-083 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Assessment
10-104B Service Verification/Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-166A Behavioral Rehabilitation Services Referral
10-182 Home Study File Checklist (Children's Administration)
10-182A Unlicensed File Checklist
10-182B Provisional Expedited File Checklist
10-183 Foster Home Inspection Checklist (Children's Administration)
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 AFH / ARC Provider Referral Letter
10-234 Individual with Challenging Support Issues (DDA)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
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
10-258 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)
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
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 Provider Report
10-334 Monitoring of Side Effects Scale (MOSES) (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 Regional Review Tool
10-351 Disclosure of Services Required by RCW 18.20.300
10-353 Documentation Request for Medical or Disability Condition
10-354 Family Home Study Application (Children's Administration)
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
10-377 Notification of Age Four (4) Eligibility Expiration-
10-378 Notification of Age Ten (10) Eligibility Expiration
10-382 Naturalization Services Pre-Screening
10-389 Room List For Assisted Living Facilities (ALF)
10-389A Additional Room List For Assisted Living Facilities (ALF)
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 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
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 Approval 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
10-442 Goal Setting and Action Planning Worksheet
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 and Adoption Home Study Updates
10-454 Children's Administration Caregiver Authorization
10-455 Medical Log (Children's Administration)
10-458 Home Study Referral Notice (Children's Administration)
10-459 Courtesy Supervision Referral
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)
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-468 HCS / AAA / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
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)
10-477 Adoption Support Program Application Checklist (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 Family Assessment Response (FAR) Closing Letter (Children's Administration)
10-498A Family Assessment Response (FAR) Closing Letter (Translated Survey Enclosed)
10-499 Education Plan (Children's Administration)
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-502 Family Plan for Change
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
10-512A Comprehensive Review: Medically Fragile 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
10-535 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
10-545 Family Feedback Questionnaire
10-565 Medical Exemption for Influenza Vaccination
10-566 Contracted Health and Safety Visit Referral
10-567 Contracted Health and Safety Visit Report
10-570 Intake and Referral
10-571 Overnight Planned Respite Services Individualized Agreement
10-572 Respite Application for Overnight Planned Respite (OPRS), Emergent and/or Planned Short-Term Stay Services at an RHC
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-574 Roads to Community Living (RCL) Person Centered Transition Planning
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-578 Licensing Application Checklist (Division of Licensed Resources)
10-580 Adult Day Services Referral
10-581 Unlicensed Placement Application Checklist
10-582 Notification of Age Twenty (20) Eligibility Review (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-585 Adult Family Home Information Changes
10-589 Comprehensive Functional Assessment of Recreation
10-590 Comprehensive Functional Assessment of Physical Therapy
10-591 Assisted Living Facility License Application
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-593 Restraint / Support Evaluation
10-593A Restraint / Support Evaluation Continuation
10-594 Comprehensive Functional Assessment of Communication
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-601 Assisted Living Facility Information Changes
10-602 Enhanced Services Facility Information Changes
10-603 Nursing Home Information Changes
10-604 Supported Living Information Changes (Residential Care Services)
10-605 ICF / IID Information Changes (Residential Care Services)
10-608 CCSP Provider Information (Child Care Subsidy Program)
10-609 CCSP Family, Friend and Neighbor Provider Denial Notice (Child Care Subsidy Program)
10-610 DDA PASRR Significant Change Review (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-612 Certified Community Residential Services and Supports (CCRSS) Pre-Certification Evaluation Preparation (Residential Care Services)
10-613 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
11-019 Vocational Information (Division of Vocational Rehabilitation)
11-022 Application for Vocational Rehabilitation Services
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-034B Basic Food Eligibility Requirements: What You Need to Know
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 Communication Technology Request (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 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
11-088 Interagency Agreement - DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing)
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-098 Vocational Assessment Worksheet
11-100 Community Rehabilitation Program (CRP) Generic Update Report
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
11-107 Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation)
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
11-111 Pre-ETS (Pre-Employment Transition Services) Job Exploration (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation)
11-113 Pre-ETS (Pre-Employment Transition Services) Social Skills (Division of Vocational Rehabilitation)
11-114 Referral Contact Sheet
11-115 Workplace Readiness Report
11-116 Work-Based Learning Report
11-117 Student Summary Report
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
11-123 Service Delivery Outcome Plan: WBL - Experience A
11-124 Service Delivery Outcome Plan: WBL - Experience B
11-125 Service Delivery Outcome Plan: WBL - Experience C
11-132 90 Day Review (Division of Vocational Rehabilitation)
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
11-142 Service Delivery Outcome Plan: Pre-ETS IL Skills Training
11-146 Supported Employment Referral (Economic Services Administration)
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 Benefits
12-207 Application for Disaster Cash Assistance
12-209 Client Fraud Report
12-210 Medicaid Provider Fraud Report
13-001 Applicant Medical Report - Confidential
13-021 Physical Evaluation
13-433 Transfer/Discharge Health Summary (Juvenile Rehabilitation)
13-585A Range of Joint Motion Evaluation Chart
13-645 Adult Family Home Injuries and Accidents Log
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 Personal Care Authorization (BHO / MCO) (Aging and Long-Term Support Administration)
13-713 Fast Track Service Agreement
13-734 Documentation of First Use of Medicaid Benefits (DDA)
13-738 DDA / CA Request to Cost Share
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
13-784 Nursing Services Assessment
13-830 Admissions Review Team Checklist for Admission to an ICF / IID or SONF at a Residential Habilitation Center (RHC) (Developmental Disabilities Administration)
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
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
13-906 Therapy Assessment Bed Rails or Side Rails (Home and Community Services)
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment
13-917 CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
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
14-057D Child Support Referral Continuation
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-078 Eligibility Review
14-084 Social Service Referral
14-105 Interview Appointment for Applicant (Community Services Division)
14-113 Your Cash and Food Assistance Rights and Responsibilities
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)
14-252 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 Adult Assessment Referral (Economic Services Administration)
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-310 Client Status Change Report
14-319 Title IVE Initial Eligibility Determination for an Adoption Support Application (CA)
14-332 Disability Assessment
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-349 Protective Payee Assessment
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)
14-416 Eligibility Review for Long Term Services and Supports
14-417 Child Care Subsidy Programs (CCSP) Application
14-417A Family, Friend and Neighbor (FFN) In-Home / Relative Pending Letter
14-417B Family, Friend or Neighbor (FFN) Provider Change Letter
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
14-446 Declaration of Financial Status Declaration of Financial Status for Adoption Support Application (Children's Administration)
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 Services and Supports
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 Inventory for Client and Agency Planning (ICAP) Letter
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Treatment Verification Request
14-484 Nurse Delegation: Nursing Visit
14-489 SSIF Introduction Letter
14-491 NSA Representative Checklist forDDA Review
14-492 Assessment Meeting Wrap-up
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
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)
14-525 Incapacity Review for Medical Care Services
14-526 Chemical Dependency Treatment Verification Request
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-528 Chemical Dependency NonCooperation
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-530 Disability Review
14-531 Education and Training Voucher (ETV) Program and Passport to College Promise Scholarship Application
14-532 Authorized Representative
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
14-548 Independent (IL) / Transitional Living Grant Application (Children's Administration)
15-031 Nursing Facility Notice of Action
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 Visit 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 Child Care Subsidy Programs (CCSP) Termination Notice
15-247A Child Care Subsidy Programs (CCSP) Denial Notice
15-247C Child Care Subsidy Program (CCSP) Provider Payment Termination Notice
15-252 DRW Access Request Checklist
15-258 Safety Assessment
15-259 Safety Plan
15-259A Case Plan
15-260 Parent Information Sheet For Shared Planning Meetings and Staffings
15-266 CPT Staffing Recommendations
15-267 Attendance and Confidentiality Agreement
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 Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another
15-286 Reference Questionnaire
15-286A Adult Child Reference Questionnaire (Children's Administration)
15-290 Notification of Annual Assessment Review
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-295 Person Centered Service Plan Meeting Survey
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
15-358 Client Referral Information
15-359 Child's Physical Description
15-360 Residential Services Capacity Profile
15-362 Concurrent TANF Benefits / Family Reunification Notice of Removal from TANF Home (Children's Administration)
15-363 Visit Referral
15-363B Provider Notification of Visit / Transport Schedule Initial Intake Screening Report
15-363C Visit Coordination Plan (Children's Administration)
15-365 Community Protection Treatment Worksheet Quarterly Review
15-366 Change of Address
15-367 Background Check Administrative Review for Use by Administrative Review Unit
15-368 Educational and Training Voucher (ETV) Program Participation Agreement
15-368A Educational and Training Voucher (ETV) Program Duel Credit 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