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 Form Name(desc) File Format
10-301 Notification of Enrollment Review (Developmental Disabilities Administration)
14-491 NSA Representative Checklist forDDA Review
16-193 Nurse Aide Registry Inquiry (ADSA)
01-212 Nurse Delegation Referral and Communication
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678B Nurse Delegation: Assumption of Delegation
13-681 Nurse Delegation: Change in Medical Orders
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
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)