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.

Additionally, you may download the free Shana Informed filler to electronically complete Shana forms below. On opening your first Shana form, you will be asked to enter a registration key. Please enter 32064015014070671 (you only need to enter this once).

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.

Choose search option and begin typing the form #
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Number(asc) Form Name File Format
27-168 Authorization of Disclosure (Economic Services Administration)
27-164 Child Care Subsidy Programs (CCSP) Single Parent Declaration (Community Services)
27-156 Notice and Consent of Communication via Text
27-155 Declaration on Commercial Purposes
27-147 Housing Modification Property Release Agreement
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
27-137 Applicant Request for a Copy of Background Check Results (Children's Administration)
27-130 Authorization for Alternate EBT Cardholder
27-127 Rights of Child and Youth in Foster Care
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
27-122 HCS / AAA / DDA Individual Provider Contractor Intake
27-115 Privacy Complaint
27-110 Applicant Request for a Copy of Background Check Information
27-109 BCCU Applicant Affidavit
27-106 Family Participation Agreement (Children's Administration)
27-096 Permission to Share Documents for Reimbursement of Medical Expenses
27-095 Court Report (Children's Administration)
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
27-089 Fingerprint-Based Background Check Notice
27-082 Five Day Notice to Move (Children's Administration)
27-081 Employment and Day Program Services Providers: Mandatory Reporting of Abandonment, Abuse, Neglect, Exploitation, or Financial Exploitation of a Child or Vulnerable Adult (Developmental Disability Administration)
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
27-063 Voluntary Placement Services For Youth (Age 18-21)
27-059 Fingerprint Appointment
27-057 Voluntary Placement Services Provider Referral Letter (DDA)
27-053 Paternity Information
27-051 DSHS / Union Contract Decision Process
27-043 Contractor Intake
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
23-035 CHINS/ARY Report to Juvenile Court
23-034 Alternative Living Financial Report
21-061 Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration)
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment
21-059 Children's Staffed Residential Quality Assurance Assessment
20-289 ICJ (Interstate Compact for Juveniles) Transition Checklist (Juvenile Rehabilitation)
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
20-271 JRA Integrated Treatment Assessment (Rehabilitation Administration) 
20-260 Request for Warrant Check on JR Youth (Juvenile Rehabilitation)
20-256 Integrated Treatment Plan (Juvenile Rehabilitation)
20-253 Polygraph Notification (Juvenile Rehabilitation)
20-250 Consent for Release to Parent/Guardian/Involved Individual (Juvenile Rehabilitation)
20-247 Youth Media Release (Juvenile Rehabilitation)
20-240 Administrative Reports of Incidents (Parole Programs) (Juvenile Rehabilitation)
20-238 Administrative Report of Incidents (Juvenile Rehabilitation)
20-236 Notification and Legal Requirements (Juvenile Rehabilitation)
20-235 SchoolNotification (Juvenile Rehabilitation)
20-234 Juvenile Rehabilitation Youth Complaint
20-230 Juvenile Volunteer Project Supervisor Agreement (JR Community Facility)
20-229B Conditions of Treatment Provider Agreement (Juvenile Rehabilitation)
20-229A Conditions of Employment Employer Agreement (JR Community Facility)
20-228A Conditions of School Involvement School Agreement (JR Community Facility)
20-228 Conditions of School Involvement School Agreement (JR Community Facility)
20-227 Wanted Person Notice of Cancellation (Juvenile Rehabilitation)
20-226 Claim for Damages (Juvenile Rehabilitation)
20-225 Claim for Facility Damages (Juvenile Rehabilitation)
20-223 Parent/Guardian Notification (Juvenile Rehabilitation)
20-222 Sexual Aggression Vulnerability Youth Assessment (Juvenile Rehabilitation)
20-220 Supervisory Case Review (Juvenile Rehabilitation)
20-219 Request for Exception to Standards (Juvenile Rehabilitation)
20-216 School Behavior Records Request (Juvenile Rehabilitation)
20-215 Law Enforcement Records Request (Juvenile Rehabilitation)
20-214 Youth Suicide Precaution Tracking (Juvenile Rehabilitation)
20-201 Authorized Leave Approval (Juvenile Rehabilitation)
20-199 Room and Isolation Confinement Record (Juvenile Rehabilitation)
20-198 Sentencing Worksheet (Juvenile Rehabilitation)
20-191 Youth Personal Property Transmittal (Juvenile Rehabilitation)
20-190 Personal Property Inventory (Juvenile Rehabilitation)
20-188 JR (Juvenile Rehabilitation) Authorized Leave Order
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
18-700 Direct Deposit Authorization
18-682 Detail Sheet – Uninsured Health Care Expenses
18-681 Request for Collection of Uninsured Health Care Expenses
18-627 SSP Client Overpayment Notice (State Supplementary Program)
18-607 Child Care Verification
18-555 Financial Information Sheet
18-551 School Statement
18-544 Transmittal of Resident Personal Funds
18-504 Financial Information Sheet Instructions
18-503 Financial Information Sheet
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
18-483 Employer Payment Identification Instructions
18-464 Introduction to New Hire Reporting
18-463 New Hire Reporting Methods and Instructions
18-433 Declaration of Support Payments (Division of Child Support)
18-400 Foster Parent Reimbursement Claim and Checklist (Children's Administration)
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
18-399 Social Service Incorrect Payment Computation
18-398A Vendor Overpayment Notice
18-398 Client Overpayment Notice
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
18-176A Address Release Information Letter
18-176 Address Release Information Letter
18-097 Statement of Resources and Expenses
18-078 Application for Nonassistance Support Enforcement Services
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
17-262 Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration)
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
17-260 Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-253 DSHS Background Check System (BCS) Access Request
17-242 Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration)
17-238 ODHH Approved Sign Language Interpreter Complaints
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-227 DSHS / HCA Systems Access Request
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
17-208A PRISM Access Request for Multiple Organizations
17-194 Request for Mental Health Service Information
17-180 Personal Information Release (Economic Services Administration)
17-155 Sign Language Interpreter Registration
17-123A Request for Sign Language Interpreter
17-123 Spoken Language Interpreter Service Appointment Record
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
17-063 Authorization
17-041A Request for Children's Administration Records
17-041 Request for Records
17-011 Forms and Publications Request
16-242 Ask DSHS
16-238 Child Care Subsidy Programs (CCSP) Statement of Collateral (Community Services)
16-237A ALTSA GovDelivery Communication Request (Aging and Long-Term Support Administration)
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
16-235 Photo Release
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-230 Children's Residential Services
16-229 Educational Resources for Youth in Foster Care Through DSHS in Washington State or a Tribal Child Welfare Agency
16-220 SOLA Incident Report (DDA)
16-218 Intake Cover Letter to Tribes
16-213 Verification of Legal Status
16-205 Personal Emergency Plan Information
16-203 SIS-A Rating Key (Developmental Disabilities Administration)
16-202A Plan of Correction (5-Day Investigation)
16-202 5-Day Investigation Report
16-200 Memo to Provider for Behavior Support, Counseling, and Consultation Services
16-199 New Case/Resource Manager Technology Training Checklist
16-198 Individual Provider Notification: Stop Work Notice
16-197 Assisted Living Facility Policies and Procedures Attestation
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-194 DDA Specialty Training Sign-Up Sheet
16-193 Nurse Aide Registry Inquiry (ADSA)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-180 CCSP Rights and Responsibilities (Child Care Subsidy Programs)
16-179 Reference Cover Letter (Children's Administration)
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-107 Noncustodial Parent's Rights and Responsibilities
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
15-517 Application for Transition from Group Home to Group Training Home
15-516 Companion Home Quarterly Report (Developmental Disabilities Administration)
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
15-514 Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration)
15-513 CCSP Client Notice of Provider Resolution
15-512 Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration)
15-509 Provider Progress Report of Community Guide and Engagement Services (Developmental Disabilities Administration))
15-508 Consent and Service Agreement (Developmental Disabilities Administration)
15-496 Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration)
15-495 Individual Habilitation Plan (IHP) (Developmental Disabilities Administration)
15-494 Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration)
15-493 PASRR Client Referral
15-492 Medicaid Transformation Demonstration Service Notice
15-487 ICF/IID Complaint Investigation (Residential Care Services)
15-481 CCRSS Complaint Investigation
15-474 Notification of Age 20 Eligibility Expiration
15-473 Notification of Age 18 Eligibility Expiration
15-458 Adult Family Home Notice of Transfer or Change
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
15-455 Certificate of Exemption
15-452 Sibling Visit Report
15-451 Missed and No Show Report: Parent - Child Visit
15-450 Child Specific Caregiver Notification
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
15-448A Supported Visit Report (Children's Administration)
15-448 Visit Report: Parent - Child Visit
15-447 Exception to Rule (ETR) to Exempt Room Requirements (Home and Community Services)
15-446 Complaint Investigation
15-445 Follow-up / Monitoring Inspection
15-444 Re-Inspection
15-441 Team Coordinator (Assisted Living Facility)
15-440 Complaint Investigation (Assisted Living Facility)
15-439 Follow-up / Monitoring Inspection (Assisted Living Facility)
15-438 Inspection (Assisted Living Facility)
15-437 RCS Staff Orientation Checklist
15-436 Request for Adult Family Home Application Fee Waiver
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
15-433 Incomplete Application
15-430A Seasonal Child Care (SCC) Denial Notice
15-430 Seasonal Child Care (SCC) Client Termination Notice
15-424 Staffed Residential Cost of Care Adjustment Request
15-422 No Paid Services Group
15-420 Request For ICF / IID or SONF Admission
15-419 Refusal of Services Statement
15-398 Medically Intensive Children's Program (MICP) Application
15-389 Certified Community Residential Services and Support Initial Application
15-388 Alternative Living Review and Evaluation
15-387 Children’s Respite Application
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
15-383 Functional Behavioral Assessment (FA)
15-382 Positive Behavior Support Plan (PBSP)
15-381 Respite Assessment Worksheet
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
15-379 Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration))
15-376 Skin Observation Protocols
15-366 Change of Address
15-365 Community Protection Treatment Worksheet Quarterly Review
15-363B Provider Notification of Visit / Transport Schedule Initial Intake Screening Report
15-363 Visit Referral
15-360 Residential Services Capacity Profile
15-358 Client Referral Information
15-356 DDA Community Protection Program Chaperone Agreement
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-342 Notice of Exception to Rule Decision
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-322 Long Term Care Agreement For Foster Parents or Relative Caregivers
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-313 Caregiver's Report to the Court
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-290 Notification of Annual Assessment Review
15-286A Adult Child Reference Questionnaire (Children's Administration)
15-286 Reference Questionnaire
15-282A Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another
15-280 Unlicensed Caregiver Placement Checklist (Children's Administration)
15-276 Personal Information (Children's Administration)
15-274 Assistance Available Schedule (DDA)
15-268 CPT Case Presentation Summary
15-266 CPT Staffing Recommendations
15-260 Parent Information Sheet For Shared Planning Meetings and Staffings
15-259A Case Plan
15-252 DRW Access Request Checklist
15-247C Child Care Subsidy Program (CCSP) Provider Payment Termination Notice
15-247A Child Care Subsidy Programs (CCSP) Denial Notice
15-247 Child Care Subsidy Programs (CCSP) Termination Notice
15-243 Social Services Case Reading Guide
15-215 AFH Quality Improvement Visit Assessment
15-184 Volunteer Chore Service Referral
15-031 Nursing Facility Notice of Action
14-547 Continuing Care Retirement Community (CCRC) Registration Application
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-532 Authorized Representative
14-530 Disability Review
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-528 Chemical Dependency NonCooperation
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-526 Chemical Dependency Treatment Verification Request
14-525 Incapacity Review for Medical Care Services
14-521 Your Rights (Home and Community Services)
14-520 Your DSHS Cash or Food Assistance Benefits
14-517 DSHS Letter Requesting Non Work SSN
14-515 Notice and Finding of Responsibility
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-513 Respite Care Provider Cover Letter
14-512 Application For Respite Provider Approval
14-510 Respite Provider Policy Agreement
14-503 Interim Assistance Reimbursement Agreement Cover
14-502 SSI Hearing Denial
14-501 Community Resource Declaration
14-495 Naturalization Letter
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
14-492 Assessment Meeting Wrap-up
14-491 NSA Representative Checklist forDDA Review
14-489 SSIF Introduction Letter
14-484 Nurse Delegation: Nursing Visit
14-478 Treatment Verification Request
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-467 Mid-Certification Review
14-465 Sources For Eligibility Information (DDA)
14-463 Waiver Transportation Record (DDA)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-459 Eligible Conditions Specific to Age and Type of Evidence (Developmental Disabilities Administration)
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-453 Protective Payee Decision
14-449 Unmet Need Breakdown
14-443 Financial / Social Services Communication
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
14-439 WASHCAP Application
14-438 Stop Work
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-432 Direct Deposit Enrollment
14-431 Medical / Dental Services Authorization
14-427 Teen Parent Living Assessment
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-417B Family, Friend or Neighbor (FFN) Provider Change Letter
14-417A Family, Friend and Neighbor (FFN) In-Home / Relative Pending Letter
14-417 Child Care Subsidy Programs (CCSP) Application
14-416 Eligibility Review for Long Term Services and Supports
14-402 Notice to Parents (WorkFirst)
14-401A Notification of Address Disclosure Request - Part 2
14-401 Notification of Address Disclosure Request - Part 1
14-381 WorkFirst Individual Responsibility Plan
14-349 Protective Payee Assessment
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-332 Disability Assessment
14-310 Client Status Change Report
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-299 Adult Assessment Referral (Economic Services Administration)
14-264 Application for Telecommunications Equipment
14-252 Employment Verification
14-245 Education List Checklist (Juvenile Rehabilitation)
14-238 Client Income Report
14-225 Acknowledgement of Services
14-224 Statement from Landlord/Manager
14-223 Statement from School
14-222 SUMMARY Statement of Collateral Information Summary
14-222 Statement of Collateral Information
14-162 Veteran's Referral
14-155 Senior Citizens Service Application
14-151 Request for DDA Eligibility Determination
14-144A Medical Disability Decision
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-105 Interview Appointment for Applicant (Community Services Division)
14-084 Social Service Referral
14-078 Eligibility Review
14-076 Change of Circumstances
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-057D Child Support Referral Continuation
14-057B Noncustodial Parent Child Support Enforcement Application
14-057 Child Support Referral
14-050 Statement of Health, Education, and Employment
14-012 Consent
14-001 Application for Cash or Food Assistance
13-917 CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
13-906 Therapy Assessment Bed Rails or Side Rails (Home and Community Services)
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
13-899 Review of Medical Evidence
13-893 Nurse Delegation: Request For Additional Units
13-865 Psychological / Psychiatric Evaluation
13-851C Psychoactive Medication Treatment Plan Annual Continuation of Medication
13-851A Psychoactive Medication Treatment Plan
13-851 Psychiatric Referral Summary
13-830 Admissions Review Team Checklist for Admission to an ICF / IID or SONF at a Residential Habilitation Center (RHC) (Developmental Disabilities Administration)
13-784 Nursing Services Assessment
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
13-738 DDA / CA Request to Cost Share
13-734 Documentation of First Use of Medicaid Benefits (DDA)
13-713 Fast Track Service Agreement
13-712 Personal Care Authorization (BHO / MCO) (Aging and Long-Term Support Administration)
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
13-690 Medical Services Authorization (Juvenile Rehabilitation)
13-681 Nurse Delegation: Change in Medical Orders
13-680 Nurse Delegation: Rescinding Delegation
13-678B Nurse Delegation: Assumption of Delegation
13-678A Nurse Delegation: PRN Medication
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-645 Adult Family Home Injuries and Accidents Log
13-585A Range of Joint Motion Evaluation Chart
13-433 Transfer/Discharge Health Summary (Juvenile Rehabilitation)
13-021 Physical Evaluation
13-001 Applicant Medical Report - Confidential
12-210 Medicaid Provider Fraud Report
12-209 Client Fraud Report
12-207 Application for Disaster Cash Assistance
12-206 Application for Disaster Food Benefits
12-195 Disqualification Consent Agreement
12-006 Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program
11-146 Supported Employment Referral (Economic Services Administration)
11-142 Service Delivery Outcome Plan: Pre-ETS IL Skills Training
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
11-132 90 Day Review (Division of Vocational Rehabilitation)
11-125 Service Delivery Outcome Plan: WBL - Experience C
11-124 Service Delivery Outcome Plan: WBL - Experience B
11-123 Service Delivery Outcome Plan: WBL - Experience A
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
11-117 Student Summary Report
11-116 Work-Based Learning Report
11-115 Workplace Readiness Report
11-114 Referral Contact Sheet
11-113 Pre-ETS (Pre-Employment Transition Services) Social Skills (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation)
11-111 Pre-ETS (Pre-Employment Transition Services) Job Exploration (Division of Vocational Rehabilitation)
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
11-107 Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation)
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
11-100 Community Rehabilitation Program (CRP) Generic Update Report
11-098 Vocational Assessment Worksheet
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing)
11-088 Interagency Agreement - DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
11-080 Centers for Independent Living (CILs) Title VII, Part B Monthly Report
11-079 Centers for Independent Living (CILs) Title VII, Part B, Contract Annual Report
11-078 Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation)
11-072 DVR Internship Evaluation (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-068 DVR Internship Application (Division of Vocational Rehabilitation)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
11-055 Acknowledgement of My Responsibilities As The Employer of My Individual Providers
11-046 Work Experience (WEX) Agreement (Food Stamp Employment and Training)
11-045 Work Experience (WEX) Referral (Food Stamp Employment and Training)
11-034B Basic Food Eligibility Requirements: What You Need to Know
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-022 Application for Vocational Rehabilitation Services
11-019 Vocational Information (Division of Vocational Rehabilitation)
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-613 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services)
10-612 Certified Community Residential Services and Supports (CCRSS) Pre-Certification Evaluation Preparation (Residential Care Services)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-610 DDA PASRR Significant Change Review (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-609 CCSP Family, Friend and Neighbor Provider Denial Notice (Child Care Subsidy Program)
10-608 CCSP Provider Information (Child Care Subsidy Program)
10-605 ICF / IID Information Changes (Residential Care Services)
10-604 Supported Living Information Changes (Residential Care Services)
10-603 Nursing Home Information Changes
10-602 Enhanced Services Facility Information Changes
10-601 Assisted Living Facility Information Changes
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-594 Comprehensive Functional Assessment of Communication
10-593A Restraint / Support Evaluation Continuation
10-593 Restraint / Support Evaluation
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-591 Assisted Living Facility License Application
10-590 Comprehensive Functional Assessment of Physical Therapy
10-589 Comprehensive Functional Assessment of Recreation
10-585 Adult Family Home Information Changes
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-582 Notification of Age Twenty (20) Eligibility Review (Developmental Disabilities Administration)
10-581 Unlicensed Placement Application Checklist
10-580 Adult Day Services Referral
10-578 Licensing Application Checklist (Division of Licensed Resources)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-574 Roads to Community Living (RCL) Person Centered Transition Planning
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-572 Respite Application for Overnight Planned Respite (OPRS), Emergent and/or Planned Short-Term Stay Services at an RHC
10-571 Overnight Planned Respite Services Individualized Agreement
10-570 Intake and Referral
10-565 Medical Exemption for Influenza Vaccination
10-545 Family Feedback Questionnaire
10-540 Project SafeCare Monthly Summary
10-539 Reference Questionnaire for Parent Home Study
10-537 Interstate Compact On Placement of Children (ICPC) Parent Home Study Information
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)
10-499 Education Plan (Children's Administration)
10-498A Family Assessment Response (FAR) Closing Letter (Translated Survey Enclosed)
10-492 Service Referral (Children's Administration)
10-489 Confidential Health Information Consent Agreement
10-488 Extended Foster Care Program Consent
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-486 Assisted Living Facility Food Service Observations - Attachment P
10-481 Health Action Plan (HAP)
10-480 Comprehensive Family Evaluation (Children's Administration)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-468 HCS / AAA / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-464 FamLink Access Application and Agreement (Children's Administration)
10-458 Home Study Referral Notice (Children's Administration)
10-455 Medical Log (Children's Administration)
10-454 Children's Administration Caregiver Authorization
10-453 Household Safety Inspection for Unlicensed Placements and Adoption Home Study Updates
10-448 Nurse Delegation Contract Monitoring Chart Audit
10-444 Relative Caregiver / Suitable Other Placement Fact Sheet and Home Study Checklist
10-442 Goal Setting and Action Planning Worksheet
10-438 Long-Term Care Partnership (LTCP) Asset Designation
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-436 Foster Care License Renewal Notice
10-428 Caregiver Support Plan (Children's Administration)
10-427 School District Communication
10-426 Respite Care Applicant Approval Letter
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-419 Licensing and Safety Supervision Plan For Site Specific Conditions
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
10-413 Application For Contract For Currently Licensed Boarding Home
10-412 Adult Family Home License Relinquishment Letter
10-411 Consumer Response: Do Not Hang Up Complaint
10-410 Adult Family Home License Application
10-406 Employed Foster Parent Child Care Plan
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-400 Information Request Letter
10-396 SSI Letter (DDA)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-389A Additional Room List For Assisted Living Facilities (ALF)
10-389 Room List For Assisted Living Facilities (ALF)
10-382 Naturalization Services Pre-Screening
10-378 Notification of Age Ten (10) Eligibility Expiration
10-377 Notification of Age Four (4) Eligibility Expiration-
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-365 Assisted Living Facility Resident Interview - Attachment G
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-361 Assisted Living Facility Resident List - Attachment C
10-360 Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-354 Family Home Study Application (Children's Administration)
10-353 Documentation Request for Medical or Disability Condition
10-351 Disclosure of Services Required by RCW 18.20.300
10-349 Comprehensive Regional Review Tool
10-348 Information Checklist (DDA)
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)
10-330 Request For Legal Advice
10-329 Informed Consent for ICAP
10-328 Residential Site Approval Request
10-327 Residential Staff Schedule Reporting
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
10-277 Request for Children's Residential Services
10-276 WTRS Consumer Response (Office of Deaf and Hard of Hearing)
10-272 Cross-System Crisis Plan (DDA)
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-269 Alternative Living Services Plan and Provider Report (Developmental Disabilities))
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-261 Foster Care Rate Assessment
10-258 Individual with Community Protection Issues (DDA)
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-248 Compliance Agreement
10-246 Permanency Plan
10-244 Shared Parenting Plan (Developmental Disabilities)
10-241 Report to Protective Services (Juvenile Rehabilitation)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)