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(asc) Form Name File Format
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-353 Documentation Request for Medical Condition and Residual Functional Capacity
10-351 Disclosure of Services Required by RCW 18.20.300
10-349 Comprehensive Regional Review Tool
10-348 Risk Assessment and Community Protection Program Information Checklist
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
10-329 Informed Consent for ICAP
10-328 Residential Site Approval Request
10-326A Staffed Residential Home DCYF Billing
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
10-301 Notification of Enrollment Review (Developmental Disabilities Administration)
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-272 Cross-System Crisis Plan (DDA)
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-269A Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration)
10-269 Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-244 Child and Family Engagement Plan (Developmental Disabilities)
10-238 Request for an Administrative Hearing (Residential Care Services)