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(desc) | File Format | |
|---|---|---|---|
| 15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
| 10-301 | Notification of Eligibility Review (Developmental Disabilities Administration) |
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| 15-501 | Notification of Initial Assessment Request (Developmental Disabilities Administration) | ||
| 14-491 | NSA Representative Checklist forDDA Review | ||
| 10-448 | Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration) | ||
| 16-273 | Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration) | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 10-670 | Nursing Home Facility License Application (Aging and Long-Term Support Administration) | ||
| 27-209 | Nursing Home Informal Dispute Resolution Request (Residential Care Services) | ||
| 10-603 | Nursing Home Information Changes | ||
| 10-237 | Nursing Home Transfer or Discharge Notice (Residential Care Services) | ||
| 06-181 | Nursing Services Activity Report for AAAs | ||
| 06-180 | Nursing Services Activity Report for Home and Community Services (HCS) | ||
| 02-740 | Office of Justice and Civil Rights Complaint Request |
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| 05-248 | On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 10-669 | Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations) | ||
| 27-063 | Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration) | ||
| 13-920 | Outpatient Competency Restoration Program (OCRP) Discharge Summary | ||
| 20-333 | Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration) | ||
| 17-294 | Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration) |
