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.

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.

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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 Able Bodied Adults Without Dependents (ABAWD) Activity Report
01-210 Transmittal of Client Funds from the Protective Payee
01-212 Nurse Delegation Referral and Communication
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
02-528 Fair Hearing Withdrawal
02-531 Native Language Identifier
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
02-566 Protected Health Information (PHI) Amendment
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 and Translator Continuing Education Activity
02-611 Statement of Understanding: Mid-Certification Review
02-615 Social Services Invoice / Receipt Packet Cover (Home and Community Services)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
02-690 Student Evaluation Summary Report
02-691 Student Class Evaluation
02-692 Community Instructor Class List Tracking Log
02-709 Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration)
02-714 DSHS Virtual Classroom Training Application (Home and Community Services)
02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
02-716 Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration)
02-740 Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services)