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.
| Number(asc) | Form Name | File Format | |
|---|---|---|---|
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-645 | Adult Family Home Injuries and Accidents Log | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-021 | Physical Evaluation | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 12-210 | Medicaid Provider Fraud Report | ||
| 12-209 | Client Fraud Report | ||
| 12-207 | Application for Disaster Cash Assistance | ||
| 12-206 | Application for Disaster Food Benefits | ||
| 12-195 | Disqualification Consent Agreement | ||
| 12-008 | Basic Food Affidavit Replacement for Household Disaster |
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| 11-194 | Waiver Stabilization Services Progress and Transition Report (Developmental Disabilities Administration) | ||
| 11-193 | Request to Provide CRP-IL Services and Background Check: Update Account (Division of Vocational Rehabilitation) | ||
| 11-192 | Request to Provide CRP-IL Services and Background Check: Create Account (Division of Vocational Rehabilitation) | ||
| 11-180 | Discovery Profile Report (Division of Vocational Rehabilitation) | ||
| 11-168 | Internship: Customer Evaluation | ||
| 11-167 | Internship: Employer Evaluation | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-164A | Pre-ETS Service Identification (Pre-Employment Transition Services (Pre-ETS) Division of Vocational Rehabilitation) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) |
