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 | |
|---|---|---|---|
| 14-105 | Interview Appointment for Applicant (Community Services Division) |
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| 17-301 | Medical Expense Examples (Community Services Division, Economic Services Administration) | ||
| 16-201 | New Case / Resource Manager Assessment (Developmental Disabilities Administration) |
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| 16-199 | New Case/Resource Manager Technology Training Checklist | ||
| 10-448 | Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration) | ||
| 06-180 | Nursing Services Activity Report for Home and Community Services (HCS) | ||
| 13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
| 15-567 | On-the-Job Facility Training Plan Application and Updates (Home and Community Services) | ||
| 07-103A | Participant Reimbursement with Interpreter Declaration | ||
| 10-643 | PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 00-398 | Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 00-399 | Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 05-273 | Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services) | ||
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 13-940 | RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services) | ||
| 13-945 | RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) | ||
| 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 | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 13-939 | Residential Care Services (Adult Family Home, Assisted Living Facility, Enhanced Services Facility) Community Programs Infection Prevention and Control (ICP) InspectionTool | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) | ||
| 15-596 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services) | ||
| 15-560 | Room Requirements Checklist (Home and Community Services) | ||
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) |
