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(asc) File Format
14-224 Statement from Landlord/Manager
10-625 State Task Checklist (Aging and Long-Term Support Administration)
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-626 Staffing Pattern (Aging and Long-Term Support Administration)
15-424 Staffed Residential Cost of Care Adjustment Request
10-210 Staff Statement of Qualifications
10-631 Staff Qualification and Background Review (Aging and Long-Term Support Administration)
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
15-379 Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration))
17-123 Spoken Language Interpreter Service Appointment Record
10-658 Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration)
06-199 Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
18-399 Social Service Incorrect Payment Computation
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
14-155 Senior Citizens Service Application
07-098 Self Employment Monthly Sales and Expense Worksheet
18-551 School Statement
10-389 Room List For Assisted Living Facilities (ALF)
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
13-899 Review of Medical Evidence