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.
| Number(desc) | Form Name | File Format | |
|---|---|---|---|
| 11-118 | Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation) | ||
| 11-119 | Informational Interview Worksheet (Division of Vocational Rehabilitation) | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) | ||
| 11-132 | 90 Day Review (Division of Vocational Rehabilitation) | ||
| 11-133 | Jobs and Training Inventory (Division of Vocational Rehabilitation) | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 11-146 | Supported Employment Referral (Economic Services Administration) |
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| 11-149 | Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet | ||
| 11-152 | Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services) | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 11-154 | Personal Pathway | ||
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-180 | Discovery Profile Report (Developmental Disabilities Administration) | ||
| 12-008 | Basic Food Affidavit Replacement for Household Disaster | ||
| 12-206 | Application for Disaster Food Benefits | ||
| 12-207 | Application for Disaster Cash Assistance | ||
| 12-209 | Client Fraud Report | ||
| 12-210 | Medicaid Provider Fraud Report | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678B | Nurse Delegation: Assumption of Delegation |
