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
15-381 Respite Assessment Worksheet
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
15-360 Residential Services Capacity Profile
15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration)
17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
15-494 Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration)
17-041 Request for Records
17-194 Request for Mental Health Service Information
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
10-673 Request for ICF/IID or SONF Services at an RHC Administration Application
05-013 Request for Hearing
13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration)
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
15-282A Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another
14-151 Request for DDA Eligibility Determination
09-520 Request for Conference Board
18-681 Request for Collection of Uninsured Health Care Expenses
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-238 Request for an Administrative Hearing (Residential Care Services)