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.

Choose search option and begin typing the form #
Keyword Search
Number Form Name(desc) File Format
06-193 DPI Statement of Shared Housing Costs (Division of Program Integrity)
06-196 DPI Tribal Income Verification (Division of Program Integrity)
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
17-227 DSHS / HCA Systems Access Request
17-253 DSHS Background Check System (BCS) Access Request
27-221 DSHS Claim of Stolen EBT Benefits
04-452A DSHS Community Services Customer Survey (Community Services Division)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
14-517 DSHS Letter Requesting Non Work SSN
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
02-744 DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services)
27-182 DSHS Request for Positive Identification – Thumbprint
03-509 DSHS Unpaid Intern / Volunteer Application
02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
15-599 Early Engagement of Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
14-078 Eligibility Review
14-416 Eligibility Review for Long Term Services and Supports