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 | |
|---|---|---|---|
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | ||
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | ||
| 10-334 | Monitoring of Side Effects Scale (MOSES) (DDA) | ||
| 10-331 | DDA Mortality Review Provider Report (Developmental Disabilities Administration) | ||
| 10-329 | Informed Consent for ICAP | ||
| 10-328 | Residential Site Approval Request | ||
| 10-326 | Staffed Residential Rate Proposal (Developmental Disabilities Administration) | ||
| 10-301 | Notification of Enrollment Review (Developmental Disabilities Administration) |
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| 10-277 | Request for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 10-272 | Cross-System Crisis Plan (DDA) | ||
| 10-270 | Assisted Living Facility Admission Agreement(s) Attestation | ||
| 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) | ||
| 10-268 | Pre-Placement Agreement (Developmental Disabilities Administration) | ||
| 10-258 | Individual With Possible Community Protection Issues (Developmental Disabilities Administration) | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
| 10-244 | Child and Family Engagement Plan (Developmental Disabilities) |
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| 10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
| 10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
| 10-234A | Individual with Complex Behaviors (Aging and Long-Term Support Administration) | ||
| 10-234 | Individual with Challenging Support Issues (DDA) | ||
| 10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
| 10-231 | Adult Family Home (AFH) Referral Checklist (DDA) | ||
| 10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | ||
| 10-210 | Staff Statement of Qualifications |
