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.
Number(desc) | Form Name | File Format | |
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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) |
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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 |
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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 |