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(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) | ||
| 02-615 | Social Services Invoice / Receipt Packet Cover (Home and Community Services) | ||
| 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) | ||
| 02-744 | DSHS Remote Skills Training Application: Virtual Classroom (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) |
