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
05-256 Notice of Action Exception to Rule for AFH Daily Rates
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
05-249 Adult Residential Care Services Notice of a Change
05-248 On-Site Review (Office of Refugee and Immigrant Assistance)
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-013 Request for Hearing
05-010 Rule Exception Request
04-452A DSHS Community Services Customer Survey (Community Services Division)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
03-509 DSHS Unpaid Intern / Volunteer Application
03-506 Character, Competence, and Suitability Assessment
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-391 Report of Possible Client Assault
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
03-387A DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-374E Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access)
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
03-077 Release of All Claims
03-076 Employee Personal Property Damage/Loss Claim