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(desc) Form Name File Format
15-603 Enhanced Services Facility Medication Observation Worksheet (Residential Care Services)
15-604 Adult Family Home (AFH) Local Building Inspection Checklist (Residential Care Services)
15-605 Certification Evaluation Checklist Intensive Habilitation Services for Children Providers (Home and Community Living Administration (HCLA)
15-606 Certification Evaluation Checklist Children’s Residential Habilitation Providers
15-607 DDCS Overnight Respite Services Provider Application (Developmental Disabilities Community Services)
15-608 Certification Evaluation Checklist Enhanced Respite Services for Children (Home and Community Living Administration)
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
16-107 Noncustodial Parent's Rights and Responsibilities
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-193 Nurse Aide Registry Inquiry (ADSA)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-197 Assisted Living Facility Policies and Procedures Attestation
16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration)
16-202 5-Day Investigation Report (Developmental Disabilities Administration (DDA)
16-202A Corrective Action Plan (Developmental Disabilities Administration)
16-205 Personal Emergency Plan Information (Developmental Disabilities Administration (DDA))
16-213 Verification of Legal Status
16-218 Intake Cover Letter to Tribes
16-230 Children's Residential Services
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))
16-235 Photo Release
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)