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 Form Name(desc) File Format
02-690 Student Evaluation Summary Report
11-114 Student Workshop Roster
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-527 Substance Use Disorder Requirements (HEN Referral Program)
11-146 Supported Employment Referral (Economic Services Administration)
10-604 Supported Living Information Changes (Residential Care Services)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
10-633 TB Testing Review for Resident (Aging and Long-Term Support Administration)
10-632 TB Testing Review for Staff (Aging and Long-Term Support Administration)
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
02-586 Temporary Employment Hours Tracking Log
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
01-210 Transmittal of Client Funds from the Protective Payee
18-544 Transmittal of Resident Personal Funds
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
18-398A Vendor / Provider Overpayment Notice
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
17-299 Vendor Agreement Information (Behavioral Health Administration)
16-213 Verification of Legal Status
11-098 Vocational Assessment Worksheet
11-019 Vocational Information (Division of Vocational Rehabilitation)
10-424 Voluntary Participation Statement (Developmental Disability Administration)