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(asc) | Form Name | File Format | |
|---|---|---|---|
| 10-560 | Provider / Resident Manager Interview (Residential Care Services) | ||
| 10-559B | Administrative Records Review - Former Staff and Others with Unsupervised Access (Residential Care Services) | ||
| 10-559A | Administrative Records Review Continuation (Residential Care Services) | ||
| 10-559 | Administrative Records Review (Residential Care Services) | ||
| 10-558A | Condensed Resident / Representative Interview (Residential Care Services) | ||
| 10-558 | Comprehensive Resident / Representative Interview (Residential Care Services) | ||
| 10-557 | Resident Medication Review (Residential Care Services) | ||
| 10-556 | Resident Record Review (Residential Care Services) | ||
| 10-555 | Resident Observations (Residential Care Services) | ||
| 10-554 | Environmental Tour - Bedrooms (Residential Care Services) | ||
| 10-553 | Environmental Tour (Residential Care Services) | ||
| 10-552 | Staff List (Residential Care Services) | ||
| 10-551 | Resident List (Residential Care Services) | ||
| 10-550 | Entrance Information and Observation (Residential Care Services) | ||
| 10-549 | Inspection Process and Records Request (Residential Care Services) | ||
| 10-548 | Pre-Inspection Preparation (Residential Care Services) | ||
| 10-535 | Enhanced Services Facility Application | ||
| 10-509 | Pediatric Symptoms Checklist (PSC-17) | ||
| 10-508 | Adult Family Home Disclosure of Services Required by RCW 70.128.280 | ||
| 10-506 | Limitation Extension Request Checklist | ||
| 10-505 | Limitation Extension Task Explanation | ||
| 10-504 | Limitation Extension Request for Clients Under Age 21 | ||
| 10-503 | Limitation Extension Evaluation | ||
| 10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) | ||
| 10-489 | Confidential Health Information Consent Agreement |
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