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
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
27-225 DSHS Claim of Stolen EBT Benefits: Food (Community Services Division)
14-517 DSHS Letter Requesting Non Work SSN
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
27-182 DSHS Request for Positive Identification – Thumbprint
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
14-416 Eligibility Review for Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
10-697 Emergency Transitional Support Services Certification Evaluation (Developmental Disabilities Administration)
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-076 Employee Personal Property Damage/Loss Claim
27-081 Employment and Day Program Services Providers: Mandatory Reporting of Abuse, Improper Use of Restraint, Neglect, Personal or Financial Exploitation, Abandonment of a Child or Vulnerable Adult (Developmental Disability Administration)
15-582 Enhanced Services Facility (ESF) Exit Preparation Worksheet
15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet
15-581 Enhanced Services Facility (ESF) Notes / Worksheets
15-576 Enhanced Services Facility (ESF) Other Contact Interview
15-572 Enhanced Services Facility (ESF) Request for Documentation
15-578 Enhanced Services Facility (ESF) Resident Record Review