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
02-740 Office of Justice and Civil Rights Complaint Request
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
06-181 Nursing Services Activity Report for AAAs
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-603 Nursing Home Information Changes
27-209 Nursing Home Informal Dispute Resolution Request (Residential Care Services)
10-670 Nursing Home Facility License Application (Aging and Long-Term Support Administration)
15-031 Nursing Facility Notice of Action
13-893 Nurse Delegation: Request For Additional Units
13-681 Nurse Delegation: Change in Medical Orders
13-678B Nurse Delegation: Assumption of Delegation
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
10-448 Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration)
14-491 NSA Representative Checklist forDDA Review
15-501 Notification of Initial Assessment Request (Developmental Disabilities Administration)
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
10-377 Notification of Age Four (4) Eligibility Expiration-
14-401A Notification of Address Disclosure Request - Part 2
14-401 Notification of Address Disclosure Request - Part 1
14-402 Notice to Parents (WorkFirst)
15-569 Notice of Termination of Service (Developmental Disabilities Administration)
06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration)