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(asc) File Format
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
02-740 Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services)
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
15-594 Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration)
27-115 Privacy Complaint
17-208A PRISM Access Request for Multiple Organizations
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
17-284 Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
16-288 Pre-Occupancy Worksheet: Resident Room / Bathroom (Residential Care Services)
16-287 Pre-Occupancy Inspection Checklist (Surveyor Use) (Residential Care Services)
16-284 Pre-Occupancy Inspection Checklist (NH Administrator Use) (Residential Care Services)
10-548 Pre-Inspection Preparation (Residential Care Services)
11-114 Pre-ETS Student Sign-In Roster (Division of Vocational Rehabilitation)
11-164A Pre-ETS Service Identification (Pre-Employment Transition Services (Pre-ETS) Division of Vocational Rehabilitation)
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-321 Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
15-382 Positive Behavior Support Plan (PBSP)
10-708 Planning for Youth Aged 18-21 Receiving RHDY Services (Developmental Disabilities Administration)
10-648 Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration)
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
14-456 Physician Certification for Home Maintenance Allowance (HMA) (Home and Community Services)
13-021 Physical Evaluation
16-235 Photo Release