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(asc) Form Name File Format
10-668 PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
10-665 Alternative Living Provider Application (Developmental Disabilities Administration)
10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration)
10-663 Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration)
10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-660 Community Engagement Quarterly Progress Report (Developmental Disabilities Administration)
10-658 Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-657 Initial Specialized Habilitation Plan (Developmental Disabilities Administration)
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
10-655 Initial Staff and Family Consultation Plan (Developmental Disabilities Administration)
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-650A Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-649 Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration)
10-648 Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration)
10-647 Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration)
10-646 Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration)
10-645 Residential Certification Evaluation Client Interview (Developmental Disabilities Administration)
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration)
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
10-641 Community Instructor Qualification Tool (Home and Community Services)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)