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(asc) | File Format | |
|---|---|---|---|
| 10-269A | Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration) | ||
| 10-269 | Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration) | ||
| 10-679 | Alternative Living Provider Application, Certification, and Contracting Checklist (Home and Community Living Administration) | ||
| 10-665 | Alternative Living Provider Application (Home and Community Living Administration) | ||
| 15-388 | Alternative Living Certification Evaluation (Home and Community Living Administration) | ||
| 17-116 | AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion | ||
| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 10-728 | Agency Alternative Living Provider Supplemental Information (Developmental Disabilities Community Services) | ||
| 14-478 | Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation |
|
|
| 10-638 | AFH Meaningful Day - Monthly Activities and Challenging Behavior Log | ||
| 06-168 | AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services) | ||
| 06-169 | AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services) | ||
| 09-052 | Affidavit of Forged Endorsement | ||
| 05-249 | Adult Residential Care Services Notice of a Change | ||
| 06-188 | Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration) |
|
|
| 27-178 | Adult Protective Services (APS) Administrative Hearing Request | ||
| 10-711 | Adult Family Homes Program Training Plan (Residential Care Services) | ||
| 14-551 | Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
| 15-559 | Adult Family Home Referral Request (Developmental Disabilities Administration) | ||
| 16-268 | Adult Family Home Post-Licensing Instructions (Residential Care Services) | ||
| 27-223 | Adult Family Home Policies and Procedures Attestation | ||
| 16-269 | Adult Family Home No One Home Letter (Residential Care Services) | ||
| 27-226 | Adult Family Home Management Agreement: Attestation Information and Attachments (Residential Care Services) | ||
| 10-412 | Adult Family Home License Relinquishment Letter |
