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 | |
|---|---|---|---|
| 02-740 | Office of Justice and Civil Rights Complaint Request |
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| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 02-714A | DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services) | ||
| 02-714 | DSHS Virtual Classroom Training Application (Home and Community Services) | ||
| 02-709 | Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) | ||
| 02-692 | Community Instructor Class List Tracking Log | ||
| 02-691 | Student Class Evaluation | ||
| 02-690 | Student Evaluation Summary Report | ||
| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 02-615 | Social Services Invoice / Receipt Packet Cover (Home and Community Services) | ||
| 02-611 | Statement of Understanding: Mid-Certification Review |
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| 02-592 | Application for Approval of Interpreter and Translator Continuing Education Activity | ||
| 02-589 | Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration) | ||
| 02-586 | Temporary Employment Hours Tracking Log | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
| 02-528 | Fair Hearing Withdrawal |
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| 02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
| 01-212 | Nurse Delegation Referral and Communication | ||
| 01-210 | Transmittal of Client Funds from the Protective Payee | ||
| 01-205 | Able Bodied Adults Without Dependents (ABAWD) Activity Report | ||
| 01-110C | Protective Payee Report Continuation | ||
| 01-110A | Protective Payee Periodic Social Services Report | ||
| 01-110 | Protective Payee Report |
