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(desc) File Format
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
17-333 Assisted Living Facility / Enhanced Services Facility / Adult Family Home Request for Records (Residential Care Services)
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-577 Assisted Living Facility Follow Up Visit
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-601 Assisted Living Facility Information Changes
10-591 Assisted Living Facility License Application
10-696 Assisted Living Facility Medication Observation Worksheet (Home and Community Living Administration)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-366 Assisted Living Facility Other Contact Interview - Attachment H
16-197 Assisted Living Facility Policies and Procedures Attestation
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-576 Assisted Living Facility Pre-Inspection Preparation (Residential Care Services)
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-362A Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-361 Assisted Living Facility Resident List - Attachment C
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-717 Assisted Living Facility Staff Interview - Attachment F (Home and Community Living Administration)