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
10-382 Naturalization Services Pre-Screening
10-377 Notification of Age Four (4) Enrollment Expiration-
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-365 Assisted Living Facility Resident Interview - Attachment G
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-362A Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-361 Assisted Living Facility Resident List - Attachment C
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-353 Documentation Request for Medical Condition and Residual Functional Capacity
10-351 Disclosure of Services Required by RCW 18.20.300
10-349 Comprehensive Regional Review Tool
10-348 Risk Assessment and Community Protection Program Information Checklist
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
10-329 Informed Consent for ICAP