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 | |
|---|---|---|---|
| 15-567 | On-the-Job Facility Training Plan Application and Updates (Home and Community Services) | ||
| 13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
| 06-180 | Nursing Services Activity Report for Home and Community Services (HCS) | ||
| 10-448 | Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration) | ||
| 16-199 | New Case/Resource Manager Technology Training Checklist | ||
| 16-201 | New Case / Resource Manager Assessment (Developmental Disabilities Administration) |
|
|
| 17-301 | Medical Expense Examples (Community Services Division, Economic Services Administration) | ||
| 10-672 | Meaningful Day Eligibility Checklist (Home and Community Services) | ||
| 14-105 | Interview Appointment for Applicant (Community Services Division) |
|
|
| 16-266 | Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration) | ||
| 16-267 | Integrated Settings Review for Resource Managers (Developmental Disabilities Administration) | ||
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-659 | Initial Community Engagement Plan (Developmental Disabilities Administration) | ||
| 10-258 | Individual With Possible Community Protection Issues (Developmental Disabilities Administration) | ||
| 27-203 | Individual Provider (IP) Attestation of Informal Support (Home and Community Services) | ||
| 10-644 | Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA) |
|
|
| 27-192 | Home and Community Services (HCS) Resumption of Training Attestation | ||
| 15-591 | High School Home Care Aide Instructor Application (Home and Community Services) | ||
| 13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
| 10-468 | HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 10-681 | Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration) | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 16-255 | For Field Use Only: Sex Offender Notification to Facility (Home and Community Services) | ||
| 16-253 | For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services) | ||
| 15-555 | Facility Training Program Application and Updates (Home and Community Services) |
