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 | |
|---|---|---|---|
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 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) | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) | ||
| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 10-691 | Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services) | ||
| 10-681 | Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 10-680 | Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 10-677 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review | ||
| 10-676 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review | ||
| 10-660 | Community Engagement Quarterly Progress Report (Developmental Disabilities Administration) |
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| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-653 | State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application | ||
| 10-650A | Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 10-644 | Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) |
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| 10-643 | PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) | ||
| 10-641 | Community Instructor Qualification Tool (Home and Community Services) |
