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
17-194 Request for Mental Health Service Information
17-180 Personal Information Release (Economic Services Administration)
17-123 Spoken Language Interpreter Service Appointment Record
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-063 Authorization
17-041 Request for Records
17-011 Forms and Publications Request
16-294 Pre-Occupancy Inspection Checklist (NH Administrator Use) (Residential Care Services)
16-288 Pre-Occupancy Worksheet: Resident Room / Bathroom (Residential Care Services)
16-287 Pre-Occupancy Inspection Checklist (Surveyor Use) (Residential Care Services)
16-286 RCS Nursing Home Pre-Occupancy Inspection Follow-Up Site Visit (Residential Care Services)
16-285 RCS Nursing Home Pre-Occupancy Inspection Site Visit – Initial Findings (Residential Care Services)
16-282 Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services)
16-280 Individual Integrated Settings Checklist for Residential Providers
16-279 Your Responsibility for Participation Towards Costs of Care at a Youth Transitional Care Facility (Developmental Disabilities Administration)
16-278 Exhibit E: School-to-Work Success Story (Division of Vocational Rehabilitation)
16-277 Adult Family Home (AFH) Confirmation Letter (Residential Care Services)
16-276 Diversion Navigator Interview (Office of Forensic Mental Health Services (OFMHS))
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
16-274 Exhibit B: School-to-Work County Mentorship Program Monthly Tracking and Reporting (Division of Vocational Rehabilitation)
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
16-270 Adult Family Home Agrees to Postpone Inspection Date Letter (Residential Care Services)
16-269 Adult Family Home No One Home Letter (Residential Care Services)
16-268 Adult Family Home Post-Licensing Instructions (Residential Care Services)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)