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
10-601 Assisted Living Facility Information Changes
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-577 Assisted Living Facility Follow Up Visit
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-372 Assisted Living Facility Contract Requirements - Attachment N
17-333 Assisted Living Facility / Enhanced Services Facility / Adult Family Home Request for Records (Residential Care Services)
27-276 Assisted Living Facility (ALF) Exhibit 359 Five Working Days Incident Follow-up Report
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
16-346 Assisted Living Facilities (ALF) Certified Memory Care Disclosure (Residential Care Services)
10-745 Assisted Living Facilities (ALF) Certified Memory Care Application (Residential Care Services)
15-274 Assistance Available Schedule (DDA)
27-189 Asset Verification Authorization (Home and Community Services)
14-492 Assessment Meeting Wrap-up
13-951 Aspiration / Choking Plan (Developmental Disabilities Administration)
16-242 Ask DSHS
27-272 Area Agency on Aging (AAA) Health-Related Social Needs (HRSN) Direct Service Approval
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
11-022 Application for Vocational Rehabilitation Services
15-517 Application for Transition from Group Home to Group Training Home
14-264 Application for Telecommunications Equipment
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)