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 | |
|---|---|---|---|
| 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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| 11-193 | 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) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) | ||
| 11-154 | Personal Pathway | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 11-152 | Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) | ||
| 11-149 | Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet | ||
| 11-146 | Supported Employment Referral (Economic Services Administration) |
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| 11-142 | Service Delivery Outcome Plan: Pre-ETS IL Skills Training | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 11-133 | Jobs and Training Inventory (Division of Vocational Rehabilitation) | ||
| 11-132 | 90 Day Review (Division of Vocational Rehabilitation) | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) |
