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
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool
27-189 Asset Verification Authorization (Home and Community Services)
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-601 Assisted Living Facility Information Changes
10-696 Assisted Living Facility Medication Observation Worksheet (Residential Care Services)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
17-292 Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
17-063 Authorization
27-130 Authorization for Alternate EBT Cardholder
09-415 Authorization for Expenditure (Non-Employee)
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
14-532 Authorized Representative
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information