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
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-193 Nurse Aide Registry Inquiry (ADSA)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-107 Noncustodial Parent's Rights and Responsibilities
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
15-604 Adult Family Home (AFH) Local Building Inspection Checklist (Residential Care Services)
15-603 Enhanced Services Facility Medication Observation Worksheet (Residential Care Services)
15-602 Enhanced Services Facility (ESF) Monitoring Visit (Residential Care Services)
15-601 New Freedom (NF) Notice of Exception to Rule (ETR) Decision (Goods and Services)
15-600 Respite, Stabilization, and Residential Health Center (RHC) Support Referral (Developmental Disabilities Administration)
15-599 Early Engagement of Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
15-597 DDA Youth Transitional Care Facility Admission Checklist (Developmental Disabilities Administration)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
15-595 Children's Behavior Intervention Plan (Developmental Disabilities Administration)
15-594 Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration)
15-593 21-Day Competency Check Request (Behavioral Health Administration)
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
15-590 Adult Family Home (AFH) Quality Assurance Visit (Residential Care Services)
15-589C Adult Family Home (AFH) Relocation Initial Licensing Inspection (Residential Care Services)
15-589B Adult Family Home (AFH) Licensing: Resident Bedroom / Bathroom Worksheet Continuation (Residential Care Services)
15-589A Adult Family Home (AFH) LIcensing Inspection Floor Plan "Key" (Residential Care Services)
15-589 Adult Family Home (AFH) Initial Licensing Inspection (Residential Care Services)
15-586 Enhanced Services Facility (ESF) Inspection Packet