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(desc) | File Format | |
|---|---|---|---|
| 17-305 | DPI Authorization for Release of Information (Division of Program Integrity) | ||
| 06-192 | DPI Dividend and Interest Request (Division of Program Integrity) | ||
| 06-194 | DPI Statement of Earnings (Division of Program Integrity) | ||
| 06-195 | DPI Statement of Income (Division of Program Integrity) | ||
| 06-193 | DPI Statement of Shared Housing Costs (Division of Program Integrity) | ||
| 06-196 | DPI Tribal Income Verification (Division of Program Integrity) | ||
| 17-265 | DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation) | ||
| 17-227 | DSHS / HCA Systems Access Request | ||
| 15-549 | DSHS Adult Education Instructor Application (Home and Community Services) | ||
| 17-253 | DSHS Background Check System (BCS) Access Request | ||
| 04-452A | DSHS Community Services Customer Survey (Community Services Division) |
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| 04-452 | DSHS Community Services Survey (Community Services Division, Economic Services Administration) |
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| 14-517 | DSHS Letter Requesting Non Work SSN | ||
| 16-289 | DSHS New School District Notification following Mutual Acceptance into RHDY (Residential Habilitation for Dependent Youth) | ||
| 03-387 | DSHS Notice of Privacy Practices for Client Medical Information |
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| 03-387A | DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement |
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| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs |
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| 02-744 | DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services) | ||
| 27-182 | DSHS Request for Positive Identification – Thumbprint | ||
| 03-509 | DSHS Unpaid Intern / Volunteer Application | ||
| 02-714A | DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services) | ||
| 27-175 | DVR Additional Contractor Information (Division of Vocational Rehabilitation) | ||
| 11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | ||
| 17-264 | DVR Background Check Reporting (Division of Vocational Rehabilitation) | ||
| 11-071 | DVR Customer Internship Program Employer Expense Worksheet (Division of Vocational Rehabilitation) |
