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 | Form Name(desc) | File Format | |
|---|---|---|---|
| 14-484 | Nurse Delegation: Nursing Visit | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 06-123 | Nursing Assistant Training and Testing Reimbursement | ||
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | ||
| 10-713 | Nursing Care Consultant (NCC) Focused Assessment (Developmental Disabilities Administration) | ||
| 10-690 | Nursing Care Consultant Transition Tool (Developmental Disabilities Administration) | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 10-670 | Nursing Home Facility License Application (Aging and Long-Term Support Administration) | ||
| 27-209 | Nursing Home Informal Dispute Resolution Request (Residential Care Services) | ||
| 10-603 | Nursing Home Information Changes | ||
| 10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
| 13-784 | Nursing Services Assessment | ||
| 13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
| 17-238 | ODHH Approved Sign Language Interpreter Complaints | ||
| 02-740 | Office of Justice and Civil Rights Complaint Request |
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| 05-248 | On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 15-567 | On-the-Job Facility Training Plan Application and Updates (Home and Community Services) | ||
| 10-669 | Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations) | ||
| 27-063 | Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration) | ||
| 13-920 | Outpatient Competency Restoration Program (OCRP) Discharge Summary | ||
| 20-333 | Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration) | ||
| 17-294 | Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration) | ||
| 10-639 | Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration) |
