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 | Form Name(desc) | File Format | |
|---|---|---|---|
| 13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
| 10-481 | Health Action Plan (HAP) | ||
| 02-756 | High School Home Care Aide Class List Tracking Log (Home and Community Services) | ||
| 15-591 | High School Home Care Aide Instructor Application (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) | ||
| 14-553 | High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration) | ||
| 10-644 | Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) |
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| 14-554 | Household Application for Sun Bucks |
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| 27-147 | Housing Modification Property Release Agreement | ||
| 18-334 | How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs |
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| 10-605 | ICF / IID Information Changes (Residential Care Services) | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
| 27-147A | In-Home Environmental Adaptations General Utility and Repair Property Release Agreement (Aging and Long-Term Support Administration) | ||
| 14-525 | Incapacity Review for Medical Care Services |
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| 20-330 | Incident Report to DDA (Developmental Disabilities Administration) | ||
| 16-282 | Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
| 16-280 | Individual Integrated Settings Checklist for Residential Providers | ||
| 16-262 | Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration) | ||
| 10-234 | Individual with Challenging Support Issues (DDA) | ||
| 10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
| 10-258 | Individual With Possible Community Protection Issues (Developmental Disabilities Administration) | ||
| 11-118 | Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation) |
