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 | |
|---|---|---|---|
| 16-191 | SOLA Vehicle Trip Log (Developmental Disabilities Administration) | ||
| 14-465 | Sources for Eligibility Information (Developmental Disabilities Administration) | ||
| 06-159 | Specialized Evaluation and Consultation Provider Invoice (Developmental Disabilities Administration) | ||
| 06-199 | Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n | ||
| 06-159A | Specialized Evaluation and Treatment Provider Invoice (Developmental Disabilities Administration) | ||
| 17-123 | Spoken Language Interpreter Service Appointment Record | ||
| 10-396 | SSI Letter (DDA) | ||
| 14-489 | SSIF Introduction Letter |
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| 10-678 | Stabilization, Assessment, and Intervention Facility (SAIF) Program Evaluation (Developmental Disabilities Administration) | ||
| 15-379 | Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)) | ||
| 10-656 | Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration) |
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| 10-561 | Staff Interview (Residential Care Services) | ||
| 10-552 | Staff List (Residential Care Services) | ||
| 10-631 | Staff Qualification and Background Review (Aging and Long-Term Support Administration) | ||
| 10-210 | Staff Statement of Qualifications | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 10-326A | Staffed Residential Home DCYF Billing | ||
| 10-326 | Staffed Residential Rate Proposal (Developmental Disabilities Administration) | ||
| 10-626 | Staffing Pattern (Aging and Long-Term Support Administration) | ||
| 10-653 | State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application | ||
| 13-935 | State Hospital Triage Consultation and Expedited Admission (TCEA) Request | ||
| 10-625 | State Task Checklist (Aging and Long-Term Support Administration) | ||
| 14-224 | Statement from Landlord/Manager |
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| 14-223 | Statement from School | ||
| 14-436 | Statement of Adult Acting in Loco Parentis (As a Parent) |
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