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.

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Number Form Name(desc) File Format
14-050 Statement of Health, Education, and Employment
18-097 Statement of Resources and Expenses
02-611 Statement of Understanding: Mid-Certification Review
14-438 Stop Work
02-691 Student Class Evaluation
02-690 Student Evaluation Summary Report
02-758 Subleased Housing Memorandum of Understanding Renter Attestation (Developmental Disabilities Administration)
02-759 Subleased Housing Memorandum of Understanding Residential Provider Attestation (Developmental Disabilities Administration)
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-528 Substance Use Good Cause Appointment Letter (HEN Referral)
11-146 Supported Employment Referral (Economic Services Administration)
10-604 Supported Living Information Changes (Residential Care Services)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
10-633 TB Testing Review for Resident (Aging and Long-Term Support Administration)
10-632 TB Testing Review for Staff (Aging and Long-Term Support Administration)
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
14-427 Teen Parent Living Assessment
27-215 Teleservice Agreement (Developmental Disabilities Administration)
02-586 Temporary Employment Hours Tracking Log
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
17-345 Transitional Care Management Exchange of Information (Developmental Disability Administration)
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)