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(desc) Form Name File Format
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
03-374E Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access)
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
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-391 Report of Possible Client Assault
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
05-013 Request for Hearing
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-248 On-Site Review (Office of Refugee and Immigrant Assistance)
05-249 Adult Residential Care Services Notice of a Change
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
05-256 Notice of Action Exception to Rule for AFH Daily Rates
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-261 Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment)
05-262 Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
06-124 Cost of Care Adjustment (COCA) (Developmental Disabilities)
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
06-180 Nursing Services Activity Report for Home and Community Services (HCS)