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
14-078 Eligibility Review
15-599 Early Engagement of Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-069 DVR Partnership Internship Agreement (Division of Vocational Rehabilitation)
11-071 DVR Customer Internship Program Employer Expense Worksheet (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
03-509 DSHS Unpaid Intern / Volunteer Application
27-182 DSHS Request for Positive Identification – Thumbprint
02-744 DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services)
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
03-387A DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement
03-387 DSHS Notice of Privacy Practices for Client Medical Information
16-289 DSHS New School District Notification following Mutual Acceptance into RHDY (Residential Habilitation for Dependent Youth)
14-517 DSHS Letter Requesting Non Work SSN
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
04-452A DSHS Community Services Customer Survey (Community Services Division)
17-253 DSHS Background Check System (BCS) Access Request
15-549 DSHS Adult Education Instructor Application (Home and Community Services)
17-227 DSHS / HCA Systems Access Request
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
06-196 DPI Tribal Income Verification (Division of Program Integrity)
06-193 DPI Statement of Shared Housing Costs (Division of Program Integrity)