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
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)
00-410 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (Residential Care Services)
00-411 Adult Family Home (AFH) Assisted Living Facility (ALF) Enhanced Services Facility (ESF) Community Program Infection Prevention and Control (IPC) Assessment Pathway (Residential Care Services)
00-413 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services)
00-413A Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services)
01-218 Community Inclusion Rate Adjustment for Staffed Residential Rate
02-692 Community Instructor Class List Tracking Log
02-714 DSHS Virtual Classroom Training Application (Home and Community Services)
02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
02-743 Community Instructor Training Report (Home and Community Services)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
04-452A DSHS Community Services Customer Survey (Community Services Division)
05-273 Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services)
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
07-103A Participant Reimbursement with Interpreter Declaration
09-693 Declaration of Lawful Custody
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
10-348 Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration)
10-448 Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration)
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-613 Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (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)
10-617 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)
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
11-153 Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
11-164 Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation)
12-212 Waiver of Administrative Disqualification Hearing (Community Services Division)
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
14-105 Interview Appointment for Applicant (Community Services Division)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
14-501 Community Resource Declaration
14-521 Your Rights (Home and Community Services)
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
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
15-356 DDA Community Protection Program Chaperone Agreement
15-365 Community Protection Treatment Worksheet Quarterly Review
15-389 Certified Community Residential Services and Support (CCRSS) Initial Application
15-447 Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services)
15-483 Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
15-548 Adult Family Home Administrator Training Instructor Application (Home and Community Services)
15-549 Community Instructor Application: DSHS Adult Education (Home and Community Services)
15-550 Community Instructor Application (Home and Community Services)
15-551 Community Instructor Training Program Application and Updates (Home and Community Services)
15-552 Curriculum Approval Application (Home and Community Services)
15-554 Facility Instructor Application (Home and Community Services)
15-555 Facility Training Program Application and Updates (Home and Community Services)
15-556 Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration)
15-560 Room Requirements Checklist (Home and Community Services)
15-567 On-the-Job Facility Training Plan Application and Updates (Home and Community Services)
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
16-199 New Case/Resource Manager Technology Training Checklist
16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration)
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (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)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
18-097 Statement of Resources and Expenses
18-433 Declaration of Support Payments (Division of Child Support)
18-720 Client Responsibility Notice (Home and Community Services)
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
27-155 Declaration on Commercial Purposes
27-189 Asset Verification Authorization (Home and Community Services)
27-192 Home and Community Services (HCS) Resumption of Training Attestation
27-203 Individual Provider (IP) Attestation of Informal Support (Home and Community Services)
27-207 Acknowledgement Statement (Meaningful Day) (Home and Community Services)
27-208 Declaration to Adult Protective Services
27-225 DSHS Claim of Stolen EBT Benefits: Food (Community Services Division)