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(desc) Form Name File Format
16-279 Your Responsibility for Participation Towards Costs of Care at a Youth Transitional Care Facility (Developmental Disabilities Administration)
16-280 Individual Home and Community Based Settings (HCBS) Checklist for Residential Providers Resources
16-282 Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services)
16-284 Pre-Occupancy Inspection Checklist (NH Administrator Use) (Residential Care Services)
16-285 RCS Nursing Home Pre-Occupancy Inspection Site Visit – Initial Findings (Residential Care Services)
16-286 RCS Nursing Home Pre-Occupancy Inspection Follow-Up Site Visit (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)
16-289 DSHS New School District Notification following Mutual Acceptance into RHDY (Residential Habilitation for Dependent Youth)
16-302 Residency Agreement Language (Home and Community Living Administration)
16-303 Recommended Diversion Plan (Office of Forensic Mental Health)
16-343 Student Status Confirmation
16-345 Health Related Social Needs (HRSN) Home Accessibility
16-346 Assisted Living Facilities (ALF) Certified Memory Care Disclosure (Residential Care Services)
16-347 Health-Related Social Needs (HRSN) Nutritional Supports
16-348 Adult Family Home Psychology Associate Consultation Referral (Developmental Disabilities Administration)
16-349 Stabilization, Assessment, and Intervention Facility (SAIF) Providers Certification Evaluation Checklist (Developmental Disabilities Administration)
16-350 Integrated Settings Review: Individual Interviews (Developmental Disabilities Administration)
16-351 Integrated Settings Initial Screening Tool All Settings (Developmental Disabilities Administration)
17-011 Forms and Publications Request
17-041 Request for Records
17-063 Authorization
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-123 Spoken Language Interpreter Service Appointment Record
17-180 Personal Information Release (Economic Services Administration)