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(asc) | File Format | |
|---|---|---|---|
| 10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
| 10-234 | Individual with Challenging Support Issues (DDA) | ||
| 16-262 | Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration) | ||
| 16-280 | Individual Home and Community Based Settings (HCBS) Checklist for Residential Providers Resources | ||
| 15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 16-282 | Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services) | ||
| 14-525 | Incapacity Review for Medical Care Services |
|
|
| 27-147A | In-Home Environmental Adaptations General Utility and Repair Property Release Agreement (Aging and Long-Term Support Administration) | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
| 10-605 | ICF / IID Information Changes (Residential Care Services) | ||
| 18-334 | How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs |
|
|
| 15-422 | How to Request Services (Developmental Disabilities Community Services) | ||
| 27-147 | Housing Modification Property Release Agreement | ||
| 14-554 | Household Application for Sun Bucks | ||
| 10-644 | Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) |
|
|
| 14-553 | High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration) | ||
| 02-754 | High School Home Care Aide Student Evaluation Summary Report (Home and Community Services) | ||
| 02-755 | High School Home Care Aide Student Class Evaluation (Home and Community Services) | ||
| 15-591 | High School Home Care Aide Instructor Application (Home and Community Services) | ||
| 02-756 | High School Home Care Aide Class List Tracking Log (Home and Community Services) | ||
| 10-481 | Health Action Plan (HAP) | ||
| 13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
| 10-468 | HCS / AAA / ODHH / DDCS / WCF Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 15-304 | HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration) |
|
