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 | |
|---|---|---|---|
| 03-391 | Report of Possible Client Assault | ||
| 03-389A | Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) | ||
| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs |
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| 03-387A | DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement |
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| 03-387 | DSHS Notice of Privacy Practices for Client Medical Information |
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| 03-374E | Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 03-077 | Release of All Claims | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | ||
| 02-759 | Subleased Housing Memorandum of Understanding Residential Provider Attestation (Developmental Disabilities Administration) | ||
| 02-758 | Subleased Housing Memorandum of Understanding Renter Attestation (Developmental Disabilities Administration) | ||
| 02-756 | High School Home Care Aide Class List Tracking Log (Home and Community Services) | ||
| 02-755 | High School Home Care Aide Student Class Evaluation (Home and Community Services) | ||
| 02-754 | High School Home Care Aide Student Evaluation Summary Report (Home and Community Services) | ||
| 02-753 | Facility Virtual Classroom Training Application and Attestation (Home and Community Services) | ||
| 02-751 | Accommodations / Modifications Request | ||
| 02-744 | DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services) | ||
| 02-743 | Community Instructor Training Report (Home and Community Services) | ||
| 02-740 | Office of Justice and Civil Rights Complaint Request |
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| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 02-714A | DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services) | ||
| 02-714 | Community Instructors Virtual Classroom Training Application (Home and Community Services) | ||
| 02-709 | Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) |
