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(asc) | File Format | |
|---|---|---|---|
| 14-521 | Your Rights (Home and Community Services) |
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| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 18-097 | Statement of Resources and Expenses |
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| 10-653 | State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application | ||
| 02-615 | Social Services Invoice / Receipt Packet Cover (Home and Community Services) | ||
| 16-245 | Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services) |
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| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) | ||
| 15-560 | Room Requirements Checklist (Home and Community Services) | ||
| 15-596 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services) | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (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 | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community 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 | ||
| 13-945 | RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) | ||
| 13-940 | RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services) | ||
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 05-273 | Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services) | ||
| 10-650 | Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
| 00-399 | Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 00-398 | Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services) | ||
| 10-643 | PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration) | ||
| 07-103A | Participant Reimbursement with Interpreter Declaration |
