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.

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Number(desc) Form Name File Format
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-617A Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
10-641 Community Instructor Qualification Tool (Home and Community Services)
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration)
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-650A Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-660 Community Engagement Quarterly Progress Report (Developmental Disabilities Administration)
10-676 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review
10-677 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review
10-680 Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-681 Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-691 Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services)
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)