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
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-413 Application For Contract For Currently Licensed Assisted Living Facility
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-442 Goal Setting and Action Planning Worksheet
10-448 Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-489 Confidential Health Information Consent Agreement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-504 Limitation Extension Request for Clients Under Age 21
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-585 Adult Family Home Information Changes
10-589 Comprehensive Functional Assessment of Recreation
10-590 Comprehensive Functional Assessment of Physical Therapy
10-594 Comprehensive Functional Assessment of Communication
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-596 Comprehensive Functional Assessment of Adult Training Programs