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 | |
|---|---|---|---|
| 15-382 | Positive Behavior Support Plan (PBSP) | ||
| 14-538 | Pre-Admission Screening and Resident Review (PASRR) Addendum | ||
| 17-321 | Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request | ||
| 17-229 | Pre-Admission Screening and Resident Review (PASRR) Records Request | ||
| 11-110 | Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation) | ||
| 11-112 | Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation) | ||
| 11-106 | Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation) | ||
| 11-164A | Pre-ETS Service Identification (Pre-Employment Transition Services (Pre-ETS) Division of Vocational Rehabilitation) | ||
| 11-114 | Pre-ETS Student Sign-In Roster (Division of Vocational Rehabilitation) | ||
| 10-548 | Pre-Inspection Preparation (Residential Care Services) | ||
| 16-294 | Pre-Occupancy Inspection Checklist (NH Administrator Use) (Residential Care Services) | ||
| 16-287 | Pre-Occupancy Inspection Checklist (Surveyor Use) (Residential Care Services) | ||
| 16-288 | Pre-Occupancy Worksheet: Resident Room / Bathroom (Residential Care Services) | ||
| 10-268 | Pre-Placement Agreement (Developmental Disabilities Administration) | ||
| 17-284 | Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing) | ||
| 13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
| 17-208A | PRISM Access Request for Multiple Organizations | ||
| 27-115 | Privacy Complaint | ||
| 15-594 | Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 14-349 | Protective Payee Assessment |
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| 14-453 | Protective Payee Decision |
