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 Form Name(desc) File Format
15-247C Child Care Subsidy Program (CCSP) Provider Payment Termination Notice
16-202 5-Day Investigation Report
11-132 90 Day Review (Division of Vocational Rehabilitation)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
11-055 Acknowledgement of My Responsibilities As The Employer of My Individual Providers
14-225 Acknowledgement of Services
05-262 Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-261 Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment)
02-634 Additional Information Needed for ILP TANF
10-389A Additional Room List For Assisted Living Facilities (ALF)
18-176 Address Release Information Letter
18-176A Address Release Information Letter
20-238 Administrative Report of Incidents (Juvenile Rehabilitation)
20-240 Administrative Reports of Incidents (Parole Programs) (Juvenile Rehabilitation)
13-830 Admissions Review Team Checklist for Admission to an ICF / IID or SONF at a Residential Habilitation Center (RHC) (Developmental Disabilities Administration)
10-082 Adoption Support Agreement Review
09-997 Adoption Support Worksheet
14-299 Adult Assessment Referral (Economic Services Administration)
15-286A Adult Child Reference Questionnaire (Children's Administration)
10-580 Adult Day Services Referral
10-231 Adult Family Home (AFH) Placement Checklist (DDA)
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-585 Adult Family Home Information Changes
13-645 Adult Family Home Injuries and Accidents Log
10-410 Adult Family Home License Application
10-412 Adult Family Home License Relinquishment Letter
15-458 Adult Family Home Notice of Transfer or Change
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
05-249 Adult Residential Care Services Notice of a Change
09-052 Affidavit of Forged Endorsement
10-232A AFH / ARC Provider Referral Letter
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
06-168 AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services)
15-215 AFH Quality Improvement Visit Assessment
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
06-176 ALF Change in Licensed Resident Bed Capacity or Use of Rooms
23-034 Alternative Living Financial Report
15-388 Alternative Living Review and Evaluation
10-269 Alternative Living Services Plan and Provider Report (Developmental Disabilities))
16-237A ALTSA GovDelivery Communication Request (Aging and Long-Term Support Administration)
01-212 ALTSA Nurse Delegation Referral and Communication Case / Resource Manager's Request
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
15-331 Annual Assessment Checklist (Developmental Disability Administration)
13-001 Applicant Medical Report - Confidential
27-110 Applicant Request for a Copy of Background Check Information
27-137 Applicant Request for a Copy of Background Check Results (Children's Administration)
02-592 Application for Approval of Interpreter Continuing Education Activity
14-001 Application for Cash or Food Assistance
10-413 Application For Contract For Currently Licensed Boarding Home
12-207 Application for Disaster Cash Assistance
12-206 Application for Disaster Food Benefits
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
18-078 Application for Nonassistance Support Enforcement Services
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-512 Application For Respite Provider Approval
14-264 Application for Telecommunications Equipment
09-998 Application For The Adoption Support Program and/or Reimbursement of Adoption Finalization Costs
15-517 Application for Transition from Group Home to Group Training Home
11-022 Application for Vocational Rehabilitation Services
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
16-242 Ask DSHS
14-492 Assessment Meeting Wrap-up
15-274 Assistance Available Schedule (DDA)
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-486 Assisted Living Facility Food Service Observations - Attachment P
10-601 Assisted Living Facility Information Changes
10-591 Assisted Living Facility License Application
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-366 Assisted Living Facility Other Contact Interview - Attachment H
16-197 Assisted Living Facility Policies and Procedures Attestation
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-361 Assisted Living Facility Resident List - Attachment C
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
17-063 Authorization
27-130 Authorization for Alternate EBT Cardholder
09-415 Authorization for Expenditure (Non-Employee)
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
27-168 Authorization of Disclosure (Economic Services Administration)
20-201 Authorized Leave Approval (Juvenile Rehabilitation)
14-532 Authorized Representative
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
09-653 Background Check Authorization
02-573 Background check Identification Verification (Office of Deaf and Hard of Hearing)
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
11-034B Basic Food Eligibility Requirements: What You Need to Know
01-205 Basic Food Workfare Activity Report
12-006 Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program
27-109 BCCU Applicant Affidavit
10-360 Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B
10-428 Caregiver Support Plan (Children's Administration)
15-313 Caregiver's Report to the Court
15-259A Case Plan
15-481 CCRSS Complaint Investigation
07-105 CCSP Authorization Letter (Child Care Subsidy Program)
15-513 CCSP Client Notice of Provider Resolution
07-106 CCSP Eligibility Letter (Child Care Subsidy Program)
07-106C CCSP Eligibility Letter - Special Assistance for Families Experiencing Homelessness (Child Care Subsidy Program)
07-106B CCSP Eligibility Letter Waitlist Space Available (Child Care Subsidy Programs)
07-106A CCSP Eligibility Waitlist Letter (Child Care Subsidy Programs)
10-609 CCSP Family, Friend and Neighbor Provider Denial Notice (Child Care Subsidy Program)
10-608 CCSP Provider Information (Child Care Subsidy Program)
07-076 CCSP Request for Information (Child Care Subsidy Programs)
16-180 CCSP Rights and Responsibilities (Child Care Subsidy Programs)
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
13-917 CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
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)
15-455 Certificate of Exemption
15-389 Certified Community Residential Services and Support Initial Application
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (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)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-612 Certified Community Residential Services and Supports (CCRSS) Pre-Certification Evaluation Preparation (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
15-366 Change of Address
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
14-076 Change of Circumstances
14-528 Chemical Dependency NonCooperation
14-526 Chemical Dependency Treatment Verification Request
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
07-109 Child Care Subsidy Program (CCSP) Notice of Summer Change
14-417 Child Care Subsidy Programs (CCSP) Application
15-247A Child Care Subsidy Programs (CCSP) Denial Notice
27-164 Child Care Subsidy Programs (CCSP) Single Parent Declaration (Community Services)
16-238 Child Care Subsidy Programs (CCSP) Statement of Collateral (Community Services)
15-247 Child Care Subsidy Programs (CCSP) Termination Notice
18-607 Child Care Verification
15-450 Child Specific Caregiver Notification
09-741 Child Support Order Review Request
14-057 Child Support Referral
14-057D Child Support Referral Continuation
07-106D Child Welfare Continuing Child Care (CWCCC) Eligibility Letter
10-454 Children's Administration Caregiver Authorization
16-230 Children's Residential Services
21-059 Children's Staffed Residential Quality Assurance Assessment
15-387 Children’s Respite Application
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment
23-035 CHINS/ARY Report to Juvenile Court
20-226 Claim for Damages (Juvenile Rehabilitation)
20-225 Claim for Facility Damages (Juvenile Rehabilitation)
12-209 Client Fraud Report
14-238 Client Income Report
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
18-398 Client Overpayment Notice
15-358 Client Referral Information
14-310 Client Status Change Report
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
15-365 Community Protection Treatment Worksheet Quarterly Review
11-100 Community Rehabilitation Program (CRP) Generic Update Report
14-501 Community Resource Declaration
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
15-514 Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration)
15-512 Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration)
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
09-995 Companion Home Evaluation and Review (Developmental Disabilities 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)
15-516 Companion Home Quarterly Report (Developmental Disabilities Administration)
15-446 Complaint Investigation
15-440 Complaint Investigation (Assisted Living Facility)
10-248 Compliance Agreement
10-480 Comprehensive Family Evaluation (Children's Administration)
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-594 Comprehensive Functional Assessment of Communication
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-590 Comprehensive Functional Assessment of Physical Therapy
10-589 Comprehensive Functional Assessment of Recreation
10-349 Comprehensive Regional Review Tool
20-229A Conditions of Employment Employer Agreement (JR Community Facility)
20-228 Conditions of School Involvement School Agreement (JR Community Facility)
20-228A Conditions of School Involvement School Agreement (JR Community Facility)
20-229B Conditions of Treatment Provider Agreement (Juvenile Rehabilitation)
10-489 Confidential Health Information Consent Agreement
03-374E Confidential Information, Fraud and Abuse
09-989 Confidentiality Statement - Tribal Employee
14-012 Consent
15-508 Consent and Service Agreement (Developmental Disabilities Administration)
20-250 Consent for Release to Parent/Guardian/Involved Individual (Juvenile Rehabilitation)
10-411 Consumer Response: Do Not Hang Up Complaint
14-547 Continuing Care Retirement Community (CCRC) Registration Application
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)
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)
27-043 Contractor Intake
10-393 Cost Estimate Worksheet for Hearing Aids and Services
06-124 Cost of Care Adjustment Request (Developmental Disabilities)
27-095 Court Report (Children's Administration)
15-268 CPT Case Presentation Summary
15-266 CPT Staffing Recommendations
10-272 Cross-System Crisis Plan (DDA)
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
13-738 DDA / CA Request to Cost Share
15-356 DDA Community Protection Program Chaperone Agreement
15-318 DDA Crisis Diversion Bed Referral and Intake Information
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
16-194 DDA Specialty Training Sign-Up Sheet
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
09-693 Declaration of Lawful Custody
18-433 Declaration of Support Payments (Division of Child Support)
27-155 Declaration on Commercial Purposes
18-682 Detail Sheet – Uninsured Health Care Expenses
18-700 Direct Deposit Authorization
14-432 Direct Deposit Enrollment
14-332 Disability Assessment
14-530 Disability Review
09-837 Disclosure of Confidential HIV/AIDS Information
10-351 Disclosure of Services Required by RCW 18.20.300
12-195 Disqualification Consent Agreement
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
13-734 Documentation of First Use of Medicaid Benefits (DDA)
10-353 Documentation Request for Medical or Disability Condition
06-172 Domestic Violence Prevention Account
15-252 DRW Access Request Checklist
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
17-227 DSHS / HCA Systems Access Request
27-051 DSHS / Union Contract Decision Process
17-253 DSHS Background Check System (BCS) Access Request
14-517 DSHS Letter Requesting Non Work SSN
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
09-746A DSHS Sex / Kidnapping Offender Preregistration
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-068 DVR Internship Application (Division of Vocational Rehabilitation)
11-072 DVR Internship Evaluation (Division of Vocational Rehabilitation)
14-245 Education List Checklist (Juvenile Rehabilitation)
10-499 Education Plan (Children's Administration)
16-229 Educational Resources for Youth in Foster Care Through DSHS in Washington State or a Tribal Child Welfare Agency
14-078 Eligibility Review
14-416 Eligibility Review for Long Term Services and Supports
14-459 Eligible Conditions Specific to Age and Type of Evidence (Developmental Disabilities Administration)
10-406 Employed Foster Parent Child Care Plan
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-076 Employee Personal Property Damage/Loss Claim
18-483 Employer Payment Identification Instructions
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)
14-252 Employment Verification
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
06-174 Enhanced Rate Proposal
10-535 Enhanced Services Facility Application
10-602 Enhanced Services Facility Information Changes
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
15-447 Exception to Rule (ETR) to Exempt Room Requirements (Home and Community Services)
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
06-165 Extended Foster Care Denial Letter (Children's Administration)
10-488 Extended Foster Care Program Consent
02-528 Fair Hearing Withdrawal
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
04-220 Family Ancestry Chart (Children's Administration)
10-498A Family Assessment Response (FAR) Closing Letter (Translated Survey Enclosed)
10-545 Family Feedback Questionnaire
10-043 Family Home Study
10-354 Family Home Study Application (Children's Administration)
27-106 Family Participation Agreement (Children's Administration)
14-417A Family, Friend and Neighbor (FFN) In-Home / Relative Pending Letter
14-417B Family, Friend or Neighbor (FFN) Provider Change Letter
10-464 FamLink Access Application and Agreement (Children's Administration)
13-713 Fast Track Service Agreement
05-180 Federal Grant Application (Washington State Partnership Council on Juvenile Justice)
05-254 Federal Subminimum Wage Certificate Holder
14-443 Financial / Social Services Communication
07-104 Financial Communication to Social Services
18-503 Financial Information Sheet
18-555 Financial Information Sheet
18-504 Financial Information Sheet Instructions
14-068 Financial Statement (Division of Vocational Rehabilitation)
27-059 Fingerprint Appointment
27-089 Fingerprint-Based Background Check Notice
27-082 Five Day Notice to Move (Children's Administration)
15-445 Follow-up / Monitoring Inspection
15-439 Follow-up / Monitoring Inspection (Assisted Living Facility)
17-011 Forms and Publications Request
10-436 Foster Care License Renewal Notice
10-261 Foster Care Rate Assessment
18-400 Foster Parent Reimbursement Claim and Checklist (Children's Administration)
15-383 Functional Behavioral Assessment (FA)
06-170 Funding and Expenditure Data
06-171 Funding and Expenditure Data (Tribal)
10-442 Goal Setting and Action Planning Worksheet
15-494 Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration)
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
10-468 HCS / AAA / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
27-122 HCS / AAA / DDA Individual Provider Contractor Intake
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
10-481 Health Action Plan (HAP)
10-458 Home Study Referral Notice (Children's Administration)
10-453 Household Safety Inspection for Unlicensed Placements and Adoption Home Study Updates
27-147 Housing Modification Property Release Agreement
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
10-605 ICF / IID Information Changes (Residential Care Services)
15-487 ICF/IID Complaint Investigation (Residential Care Services)
20-289 ICJ (Interstate Compact for Juveniles) Transition Checklist (Juvenile Rehabilitation)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
14-525 Incapacity Review for Medical Care Services
15-433 Incomplete Application
04-220A Indian Heritage Questionnaire (Developmental Disabilities Administration)
09-539A Indian Heritage Questionnaire and Notice to an Indian Tribe, Nation or Band of Youth Committed to JR
09-761 Indian Identity Request
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
15-495 Individual Habilitation Plan (IHP) (Developmental Disabilities Administration)
15-496 Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration)
06-175 Individual Provider (IP) Travel Time Request
16-198 Individual Provider Notification: Stop Work Notice
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
06-166 Individual Training Plan (Division of Licensed Resources)
10-234 Individual with Challenging Support Issues (DDA)
10-258 Individual with Community Protection Issues (DDA)
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
10-348 Information Checklist (DDA)
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment
10-400 Information Request Letter
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
10-329 Informed Consent for ICAP
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
15-438 Inspection (Assisted Living Facility)
10-570 Intake and Referral
16-218 Intake Cover Letter to Tribes
20-256 Integrated Treatment Plan (Juvenile Rehabilitation)
11-088 Interagency Agreement - DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
14-503 Interim Assistance Reimbursement Agreement Cover
10-537 Interstate Compact On Placement of Children (ICPC) Parent Home Study Information
14-105 Interview Appointment for Applicant (Community Services Division)
18-464 Introduction to New Hire Reporting
14-473 Inventory for Client and Agency Planning (ICAP) Letter
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
20-188 JR (Juvenile Rehabilitation) Authorized Leave Order
20-271 JRA Integrated Treatment Assessment (Rehabilitation Administration) 
09-808 JRA Notice and Finding of Financial Responsibility
05-180C Juvenile Detention Alternatives Initiative Grant Application (Washington State Partnership Council on Juvenile Justice)
20-234 Juvenile Rehabilitation Youth Complaint
20-230 Juvenile Volunteer Project Supervisor Agreement (JR Community Facility)
20-215 Law Enforcement Records Request (Juvenile Rehabilitation)
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
10-419 Licensing and Safety Supervision Plan For Site Specific Conditions
10-578 Licensing Application Checklist (Division of Licensed Resources)
10-503 Limitation Extension Evaluation
10-506 Limitation Extension Request Checklist
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
15-322 Long Term Care Agreement For Foster Parents or Relative Caregivers
05-263 Long Term Care Survey Process (LTCSP) Self-Asssessment Skill Building Tool
10-438 Long-Term Care Partnership (LTCP) Asset Designation
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
12-210 Medicaid Provider Fraud Report
15-492 Medicaid Transformation Demonstration Service Notice
05-255 Medicaid Transformation Project Demonstration Notice of Action Exception to Rule
14-431 Medical / Dental Services Authorization
14-144A Medical Disability Decision
06-173 Medical Evidence Reimbursement
10-565 Medical Exemption for Influenza Vaccination
10-455 Medical Log (Children's Administration)
13-690 Medical Services Authorization (Juvenile Rehabilitation)
15-398 Medically Intensive Children's Program (MICP) Application
03-494 Medication Administration Competency Assessment Tool
16-200 Memo to Provider for Behavior Support, Counseling, and Consultation Services
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
14-467 Mid-Certification Review
15-451 Missed and No Show Report: Parent - Child Visit
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
14-495 Naturalization Letter
10-382 Naturalization Services Pre-Screening
16-199 New Case/Resource Manager Technology Training Checklist
18-463 New Hire Reporting Methods and Instructions
15-422 No Paid Services Group
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
14-057B Noncustodial Parent Child Support Enforcement Application
16-107 Noncustodial Parent's Rights and Responsibilities
27-156 Notice and Consent of Communication via Text
14-515 Notice and Finding of Responsibility
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-256 Notice of Action Exception to Rule for AFH Daily Rates
15-342 Notice of Exception to Rule Decision
09-877 Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
09-746 Notice of Sex/Kidnapping Offender Registration Requirements
14-402 Notice to Parents (WorkFirst)
20-236 Notification and Legal Requirements (Juvenile Rehabilitation)
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
15-473 Notification of Age 18 Eligibility Expiration
15-474 Notification of Age 20 Eligibility Expiration
10-377 Notification of Age Four (4) Eligibility Expiration-
10-378 Notification of Age Ten (10) Eligibility Expiration
10-582 Notification of Age Twenty (20) Eligibility Review (Developmental Disabilities Administration)
15-290 Notification of Annual Assessment Review
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
09-747 Notification of Release (Juvenile Rehabilitation Administration)
09-747A Notification of Sex Offender Release (Juvenile Rehabilitation)
14-491 NSA Representative Checklist forDDA Review
16-193 Nurse Aide Registry Inquiry (ADSA)
10-448 Nurse Delegation Contract Monitoring Chart Audit
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678B Nurse Delegation: Assumption of Delegation
13-681 Nurse Delegation: Change in Medical Orders
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
14-484 Nurse Delegation: Nursing Visit
13-678A Nurse Delegation: PRN Medication
13-893 Nurse Delegation: Request For Additional Units
13-680 Nurse Delegation: Rescinding Delegation
06-123 Nursing Assistant Training and Testing Reimbursement
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
15-031 Nursing Facility Notice of Action
04-442 Nursing Home Credit Balance Report
10-603 Nursing Home Information Changes
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
06-181 Nursing Services Activity Report for AAAs
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
13-784 Nursing Services Assessment
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
17-238 ODHH Approved Sign Language Interpreter Complaints
09-878 Order Approving Continued Out-of-Home Care (Child With a Developmental Disability)
09-713 Order Denying Parole Revocation Petition (Juvenile Rehabilitation)
09-705 Order of Continued Detention or Release (Juvenile Rehabilitation)
09-341 Order of Parole Conditions (Juvenile Rehabilitation Administration)
09-714 Order Revoking Parole (Juvenile Rehabilitation Administration)
11-093 Outreach Attendance (Office of the Deaf and Hard of Hearing)
10-571 Overnight Planned Respite Services Individualized Agreement
15-260 Parent Information Sheet For Shared Planning Meetings and Staffings
20-223 Parent/Guardian Notification (Juvenile Rehabilitation)
09-706 Parole Revocation Petition (Juvenile Rehabilitation Administration)
07-103 Participant Reimbursement
07-103A Participant Reimbursement with Interpreter Declaration
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
07-081 Participation Reimbursement
15-493 PASRR Client Referral
27-053 Paternity Information
10-509 Pediatric Symptoms Checklist (PSC-17)
09-893 Periodic Review of Individual Service Plan (DDA)
10-246 Permanency Plan
09-876 Permanency Planning Findings and Order (Child With a Developmental Disability)
27-096 Permission to Share Documents for Reimbursement of Medical Expenses
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-291 Person Centered Service Planning and Annual Assessment Meeting
13-712 Personal Care Authorization (BHO / MCO) (Aging and Long-Term Support Administration)
16-205 Personal Emergency Plan Information
15-276 Personal Information (Children's Administration)
17-180 Personal Information Release (Economic Services Administration)
20-190 Personal Property Inventory (Juvenile Rehabilitation)
09-762A Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Developmental Disabilities Administration)
09-280B Petition for Modification - Administrative Order
09-892 Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Developmental Disabilities Administration)
16-235 Photo Release
13-021 Physical Evaluation
16-202A Plan of Correction (5-Day Investigation)
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
20-253 Polygraph Notification (Juvenile Rehabilitation)
15-382 Positive Behavior Support Plan (PBSP)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
11-111 Pre-ETS (Pre-Employment Transition Services) Job Exploration (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (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)
11-113 Pre-ETS (Pre-Employment Transition Services) Social Skills (Division of Vocational Rehabilitation)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-214 Preauthorization for Services (Children's Administration)
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
17-208A PRISM Access Request for Multiple Organizations
27-115 Privacy Complaint
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
10-540 Project SafeCare Monthly Summary
14-349 Protective Payee Assessment
14-453 Protective Payee Decision
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
01-110A Protective Payee Periodic Social Services Report
01-110 Protective Payee Report
01-110C Protective Payee Report Continuation
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
15-363B Provider Notification of Visit / Transport Schedule Initial Intake Screening Report
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
15-509 Provider Progress Report of Community Guide and Engagement Services (Developmental Disabilities Administration))
10-232 Provider Referral Letter For Supported Living/Group Home Providers
13-851 Psychiatric Referral Summary
13-851A Psychoactive Medication Treatment Plan
13-851C Psychoactive Medication Treatment Plan Annual Continuation of Medication
13-865 Psychological / Psychiatric Evaluation
06-159 Psychologist and Sex Offender Treatment Provider Invoice
10-255 Public Health Nurse (PHN) Summary and Recommendations
06-182 Public Records Customer Experience Survey
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
13-585A Range of Joint Motion Evaluation Chart
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
15-437 RCS Staff Orientation Checklist
15-444 Re-Inspection
09-097 Record of Official Actions (Juvenile Rehabilitation Administration)
16-179 Reference Cover Letter (Children's Administration)
15-286 Reference Questionnaire
10-539 Reference Questionnaire for Parent Home Study
11-114 Referral Contact Sheet
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
15-419 Refusal of Services Statement
10-444 Relative Caregiver / Suitable Other Placement Fact Sheet and Home Study Checklist
03-077 Release of All Claims
03-391 Report of Possible Client Assault
10-241 Report to Protective Services (Juvenile Rehabilitation)
15-436 Request for Adult Family Home Application Fee Waiver
10-238 Request for an Administrative Hearing (Residential Care Services)
17-041A Request for Children's Administration Records
10-277 Request for Children's Residential Services
18-681 Request for Collection of Uninsured Health Care Expenses
09-520 Request for Conference Board
14-151 Request for DDA Eligibility Determination
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
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
20-219 Request for Exception to Standards (Juvenile Rehabilitation)
05-013 Request for Hearing
15-420 Request For ICF / IID or SONF Admission
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
10-330 Request For Legal Advice
17-194 Request for Mental Health Service Information
17-041 Request for Records
17-123A Request for Sign Language Interpreter
20-260 Request for Warrant Check on JR Youth (Juvenile Rehabilitation)
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
06-125 Residential Allowance Request (Developmental Disabilities Administration)
17-242 Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
15-360 Residential Services Capacity Profile