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(desc) | File Format | |
|---|---|---|---|
| 05-277 | Companion Home DCYF Weekly Schedule (Developmental Disability Administration) | ||
| 17-260 | Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration) | ||
| 21-061 | Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration) | ||
| 02-589 | Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration) | ||
| 17-262 | Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration) | ||
| 10-685 | Companion Home Provider Supplemental Information (Developmental Disabilities Administration) | ||
| 15-516 | Companion Home Quarterly Report (Developmental Disabilities Administration) | ||
| 10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) | ||
| 10-596 | Comprehensive Functional Assessment of Adult Training Programs | ||
| 10-349 | Comprehensive Regional Review Tool | ||
| 10-489 | Confidential Health Information Consent Agreement |
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| 14-012 | Consent |
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| 27-222 | Consent to Release and/or Use Confidential Information for Completing an Adult Home License Application | ||
| 14-547 | Continuing Care Retirement Community (CCRC) Registration Application | ||
| 15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
| 15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
| 14-544 | Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment) | ||
| 10-415 | Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 11-084 | Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 17-266 | Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation) | ||
| 27-044A | Contractor Information Update (for existing DSHS contractors) | ||
| 16-202A | Corrective Action Plan (Developmental Disabilities Administration) | ||
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
| 06-124 | Cost of Care Adjustment (COCA) (Developmental Disabilities) | ||
| 10-272 | Cross-System Crisis Plan (DDA) |
