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(asc) Form Name File Format
16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services)
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
16-246 Your rights as a client of the Developmental Disabilities Administration
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-213 Verification of Legal Status
16-205 Personal Emergency Plan Information (Developmental Disabilities Administration (DDA))
16-202A Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration)
16-202 5-Day Investigation Report (Developmental Disabilities Administration (DDA)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
15-595 Intensive Habilitation Services (IHS) Behavior Intervention Plan (Developmental Disabilities Administration)
15-593 21-Day Competency Check Request (Behavioral Health Administration)
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
15-589B Adult Family Home (AFH) Licensing: Resident Bedroom / Bathroom Worksheet Continuation (Residential Care Services)
15-589A Adult Family Home (AFH) LIcensing Inspection Floor Plan "Key" (Residential Care Services)
15-585B Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services)
15-585A Enhanced Services Facility (ESF) Staff Schedule Worksheet: 8-hour Shift (Residential Care Services)
15-585 Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services)
15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet