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
14-555 WA Cares Application Attestation
20-335 WA Care Fund Rights and Responsibilities
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
15-184 Volunteer Chore Service Referral
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
10-424 Voluntary Participation Statement (Developmental Disability Administration)
11-098 Vocational Assessment Worksheet
13-955 Vital Signs Tracking (Developmental Disabilities Administration)
16-213 Verification of Legal Status
17-299 Vendor Agreement Information (Behavioral Health Administration)
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
18-398A Vendor / Provider Overpayment Notice
14-449 Unmet Need Breakdown
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
18-544 Transmittal of Resident Personal Funds
01-210 Transmittal of Client Funds from the Protective Payee
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
10-574B Transitional Care Planning and Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574A Transitional Care Planning and Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
17-345 Transitional Care Management Exchange of Information (Developmental Disability Administration)
19-074 Transfer / Loan / Recovery Agreement (Division of Vocational Rehabilitation)
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility