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 | |
|---|---|---|---|
| 17-226 | AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration) | ||
| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 10-650A | Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) | ||
| 10-467 | ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services) | ||
| 27-189 | Asset Verification Authorization (Home and Community Services) | ||
| 15-515 | CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 10-619 | Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services) | ||
| 10-676 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review | ||
| 10-614 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services) | ||
| 10-677 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review | ||
| 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) | ||
| 10-691 | Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services) | ||
| 10-617A | Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet | ||
| 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) | ||
| 10-680 | Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 10-620 | Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services) | ||
| 13-943 | Certified Community Residential Supports and Services (CCRSS) Infection Prevention and Control (IPC) Complaint Investigation Pathway | ||
| 16-275 | Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services) |
