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
00-398 Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services)
00-399 Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services)
00-410 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (Residential Care Services)
00-411 Adult Family Home (AFH) Assisted Living Facility (ALF) Enhanced Services Facility (ESF) Community Program Infection Prevention and Control (IPC) Assessment Pathway (Residential Care Services)
00-412 RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility)
00-412A RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility)
00-413 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services)
00-413A Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services)
01-110 Protective Payee Report
01-110A Protective Payee Periodic Social Services Report
01-110C Protective Payee Report Continuation
01-205 Able Bodied Adults Without Dependents (ABAWD) Activity Report
01-210 Transmittal of Client Funds from the Protective Payee
01-212 Nurse Delegation Referral and Communication
01-218 Community Inclusion Rate Adjustment for Staffed Residential Rate
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
02-528 Fair Hearing Withdrawal
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
02-566 Protected Health Information (PHI) Amendment
02-586 Temporary Employment Hours Tracking Log
02-589 Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration)
02-592 Application for Approval of Interpreter and Translator Continuing Education Activity
02-611 Statement of Understanding: Mid-Certification Review
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
02-690 Student Evaluation Summary Report
02-691 Student Class Evaluation
02-692 Community Instructor Class List Tracking Log
02-709 Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration)
02-714 DSHS Virtual Classroom Training Application (Home and Community Services)
02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
02-716 Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration)
02-740 Office of Justice and Civil Rights Complaint Request
03-076 Employee Personal Property Damage/Loss Claim
03-077 Release of All Claims
03-133 Safety Incident / Close Call Report
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
03-374E Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access)
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-391 Report of Possible Client Assault
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-506 Character, Competence, and Suitability Assessment
03-509 DSHS Unpaid Intern / Volunteer Application
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
04-452A DSHS Community Services Customer Survey (Community Services Division)
05-010 Rule Exception Request
05-013 Request for Hearing
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-248 On-Site Review (Office of Refugee and Immigrant Assistance)
05-249 Adult Residential Care Services Notice of a Change
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
05-254 Federal Subminimum Wage Certificate Holder
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
05-256 Notice of Action Exception to Rule for AFH Daily Rates
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-261 Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment)
05-262 Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
05-267 Self-Assessment and Monitoring Tool (Home and Community Services)
05-268 Community Instructor Self-Assessment (Home and Community Services)
05-269 Community Instructor Self-Assessment for Contract Renewal and/or for Newly Established Contracts (Home and Community Services)
05-272 Case Manager Instructions Following a Hearing Decision
05-273 Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services)
05-274 Residential Referral Transition (Developmental Disabilities Administration)
06-123 Nursing Assistant Training and Testing Reimbursement
06-124 Cost of Care Adjustment (COCA) (Developmental Disabilities)
06-125 Residential Allowance Request / Insufficient Income (Developmental Disabilities Administration)
06-125A Residential Allowance Request - Start Up Costs (Developmental Disabilities Administration)
06-125B Residential Allowance Request - Damages (Developmental Disabilities Administration)
06-125C Residential Allowance Request - Shelter Expense (Developmental Disabilities Administration)
06-159 Specialized Evaluation and Consultation Provider Invoice (Developmental Disabilities Administration)
06-159A Specialized Evaluation and Treatment Provider Invoice (Developmental Disabilities Administration)
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
06-168 AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services)
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
06-171 Funding and Expenditure Data (Tribal)
06-172 Domestic Violence Prevention Account
06-173 Medical Evidence Reimbursement
06-174 Enhanced Rate Proposal
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
06-181 Nursing Services Activity Report for AAAs
06-184 Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services)
06-186 Financial Solvency Information (Aging and Long-Term Support Administration)
06-188 Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration)
06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration)
06-199 Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n
06-200 Registered Nurse (RN) Delegation Billing
07-042B Self-Employment Income Report
07-081 Participation Reimbursement
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
07-098 Self Employment Monthly Sales and Expense Worksheet
07-103 Basic Food Employment and Training (BFET) Participant Reimbursement
07-103A Participant Reimbursement with Interpreter Declaration
07-104 Financial Communication to Social Services
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
09-052 Affidavit of Forged Endorsement
09-280B Petition for Modification - Administrative Order
09-415 Authorization for Expenditure (Non-Employee)
09-508 Waiver of Statute of Limitations
09-520 Request for Conference Board
09-653 Background Check Authorization
09-693 Declaration of Lawful Custody
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
09-741 Child Support Order Review Request
09-989 Confidentiality Statement - Tribal Employee
09-995 Companion Home Certification Evaluation (Developmental Disabilities Administration)
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-210 Staff Statement of Qualifications
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
10-231 Adult Family Home (AFH) Referral Checklist (DDA)
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
10-232A AFH / ARC Provider Referral Letter
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-244 Child and Family Engagement Plan (Developmental Disabilities)
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-269 Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration)
10-269A Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration)
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-272 Cross-System Crisis Plan (DDA)
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
10-328 Residential Site Approval Request
10-329 Informed Consent for ICAP
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
10-348 Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration)
10-349 Comprehensive Regional Review Tool
10-351 Disclosure of Services Required by RCW 18.20.300
10-353 Documentation Request for Medical Condition and Residual Functional Capacity
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-361 Assisted Living Facility Resident List - Attachment C
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-362A Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-377 Notification of Age Four (4) Eligibility Expiration-
10-382 Naturalization Services Pre-Screening
10-389 Room List For Assisted Living Facilities (ALF)
10-389A Additional Room List For Assisted Living Facilities (ALF)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-396 SSI Letter (DDA)
10-400 Information Request Letter
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-412 Adult Family Home License Relinquishment Letter
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)
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-427 School District Communication
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-438 Long-Term Care Partnership (LTCP) Asset Designation
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)
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-481 Health Action Plan (HAP)
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
10-488 Extended Foster Care Program Consent
10-489 Confidential Health Information Consent Agreement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-503 Limitation Extension Evaluation
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
10-506 Limitation Extension Request Checklist
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-509 Pediatric Symptoms Checklist (PSC-17)
10-535 Enhanced Services Facility Application
10-570 Intake and Referral
10-571 Overnight Planned Respite Services Individualized Agreement
10-572 Planned Respite Application (Developmental Disabilities Administration)
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-574 Transitional Care Planning Tracking (Developmental Disabilities Administration)
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-580 Adult Day Services Referral
10-583 DDA PASRR Cover Sheet
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
10-591 Assisted Living Facility License Application
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-594 Comprehensive Functional Assessment of Communication
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-601 Assisted Living Facility Information Changes
10-602 Enhanced Services Facility Information Changes
10-603 Nursing Home Information Changes
10-604 Supported Living Information Changes (Residential Care Services)
10-605 ICF / IID Information Changes (Residential Care Services)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-613 Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-617A Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-625 State Task Checklist (Aging and Long-Term Support Administration)
10-626 Staffing Pattern (Aging and Long-Term Support Administration)
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
10-629 Pet Record Review (Aging and Long-Term Support Administration)
10-630 Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration)
10-631 Staff Qualification and Background Review (Aging and Long-Term Support Administration)
10-632 TB Testing Review for Staff (Aging and Long-Term Support Administration)
10-633 TB Testing Review for Resident (Aging and Long-Term Support Administration)
10-634 Medication Assistant Endorsement (Aging and Long-Term Support Administration)
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
10-636 Meaningful Day Monthly Calendar
10-637 Meaningful Activity Plan (MAP) Discovery
10-638 AFH Meaningful Day - Monthly Activities and Challenging Behavior Log
10-639 Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
10-641 Community Instructor Qualification Tool (Home and Community Services)
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration)
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
10-645 Residential Certification Evaluation Client Interview (Developmental Disabilities Administration)
10-646 Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration)
10-647 Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration)
10-648 Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration)
10-649 Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration)
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-650A Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-655 Initial Staff and Family Consultation Plan (Developmental Disabilities Administration)
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
10-657 Initial Specialized Habilitation Plan (Developmental Disabilities Administration)
10-658 Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-660 Community Engagement Quarterly Progress Report (Developmental Disabilities Administration)
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-663 Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration)
10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration)
10-665 Alternative Living Provider Application (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
10-668 PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration)
10-669 Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations)
10-670 Nursing Home Facility License Application (Aging and Long-Term Support Administration)
10-671 Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration)
10-673 Request for ICF/IID or SONF Services at an RHC Administration Application
10-676 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review
10-677 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review
10-678 Stabilization, Assessment, and Intervention Facility (SAIF) Program Evaluation (Developmental Disabilities Administration)
10-679 Alternative Living Provider Application, Contracting, and Certification Overview Checklist (Developmental Disabilities Administration)
10-680 Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-681 Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-682 Intensive Habilitation Services (IHS) Habilitation Plan (Developmental Disabilities Administration)
10-683 Enhanced Services Facility (ESF) Follow-Up (Residential Care Services)
10-685 Companion Home Provider Supplemental Information (Developmental Disabilities Administration)
10-687 DDA Specialty Adult Family Home (AFH) Pilot: Strengths, Abilities, Interests, Learn (SAIL) (Developmental Disabilities Administration)
10-688 DDA Specialty Adult Family Home (AFH) Pilot Monthly Client Goal and Progress Report (Developmental Disabilities Administration)
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-690 Nursing Care Consultant Transition Tool (Developmental Disabilities Administration)
10-691 Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services)
11-019 Vocational Information (Division of Vocational Rehabilitation)
11-022 Application for Vocational Rehabilitation Services
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-034B Basic Food Eligibility Requirements: What You Need to Know
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-068 Customer Internship Program Internship Application (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-098 Vocational Assessment Worksheet
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation)
11-114 Student Workshop Roster
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
11-123 Service Delivery Outcome Plan: WBL - Experience A
11-124 Service Delivery Outcome Plan: WBL - Experience B
11-125 Service Delivery Outcome Plan: WBL - Experience C
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)
11-142 Service Delivery Outcome Plan: Pre-ETS IL Skills Training
11-146 Supported Employment Referral (Economic Services Administration)
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)
11-167 Internship: Employer Evaluation
11-168 Internship: Customer Evaluation
11-180 Discovery Profile Report (Developmental Disabilities Administration)
12-195 Disqualification Consent Agreement
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)
13-021 Physical Evaluation
13-585A Range of Joint Motion Evaluation Chart
13-645 Adult Family Home Injuries and Accidents Log
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678A Nurse Delegation: PRN Medication
13-678B Nurse Delegation: Assumption of Delegation
13-680 Nurse Delegation: Rescinding Delegation
13-681 Nurse Delegation: Change in Medical Orders
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
13-712 Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration)
13-713 Fast Track Service Agreement
13-738 DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families)
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
13-784 Nursing Services Assessment
13-851 Psychiatric Referral Summary
13-865 Psychological / Psychiatric Evaluation
13-893 Nurse Delegation: Request For Additional Units
13-899 Review of Medical Evidence
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration)
13-917 Intensive Habilitation Services (IHS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
13-919 Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration)
13-920 Outpatient Competency Restoration Program (OCRP) Discharge Summary
13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration)
13-925A Non-Formulary Drug Use Request (Behavioral Health Administration)
13-926 Forensic (6358) Consultation (Behavioral Health Administration)
13-927 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
13-928 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
13-935 State Hospital Triage Consultation and Expedited Admission (TCEA) Request
13-936 Stabilization, Assessment, and Intervention Services (SAIF) Eligibility and Referral (Developmental Disabilities Administration)
14-001 Application for Cash or Food Assistance
14-012 Consent
14-050 Statement of Health, Education, and Employment
14-057 Child Support Referral
14-057B Noncustodial Parent Child Support Enforcement Application
14-057D Child Support Referral Continuation
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-078 Eligibility Review
14-084 Social Service Referral
14-105 Interview Appointment for Applicant (Community Services Division)
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-144A Medical Disability Decision
14-151 Request for DDA Eligibility Determination
14-155 Senior Citizens Service Application
14-223 Statement from School
14-224 Statement from Landlord/Manager
14-225 Acknowledgement of Services
14-238 Client Income Report
14-252 Employment Verification
14-264 Application for Telecommunications Equipment
14-299 Adult Assessment Referral (Economic Services Administration)
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
14-310 Client Status Change Report
14-332 Disability Assessment
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-349 Protective Payee Assessment
14-381 WorkFirst Individual Responsibility Plan
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
14-402 Notice to Parents (WorkFirst)
14-416 Eligibility Review for Long Term Services and Supports
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-427 Teen Parent Living Assessment
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
14-432 Direct Deposit Enrollment
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-438 Stop Work
14-439 Washington State Combined Application Program (WASHCAP) Application
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
14-443 Financial / Social Services Communication
14-449 Unmet Need Breakdown
14-453 Protective Payee Decision
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
14-463 Waiver Transportation Record (DDA)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
14-467 Mid-Certification Review
14-473 Inventory for Client and Agency Planning (ICAP) Letter
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
14-484 Nurse Delegation: Nursing Visit
14-489 SSIF Introduction Letter
14-491 NSA Representative Checklist forDDA Review
14-492 Assessment Meeting Wrap-up
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
14-495 Naturalization Letter
14-501 Community Resource Declaration
14-503 Interim Assistance Reimbursement Agreement Cover
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-517 DSHS Letter Requesting Non Work SSN
14-520 Your DSHS Cash or Food Assistance Benefits
14-521 Your Rights (Home and Community Services)
14-525 Incapacity Review for Medical Care Services
14-526 ABD and HEN Referral Substance Use Treatment Verification
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-528 Substance Use Good Cause Appointment Letter (HEN Referral)
14-529 Substance Use Disorder Requirements (ABD / PWA)
14-530 Disability Review
14-532 Authorized Representative
14-534 SDCP Eligibility Checklist (Home and Community Services)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)
14-550 Job Foundation Application (Developmental Disabilities Administration)
14-551 Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
14-553 High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration)
15-031 Nursing Facility Notice of Action
15-184 Volunteer Chore Service Referral
15-215 AFH Quality Improvement Visit Assessment
15-274 Assistance Available Schedule (DDA)
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
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-342 Notice of Exception to Rule Decision
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-356 DDA Community Protection Program Chaperone Agreement
15-358 Client Referral Summary (Developmental Disabilities Administration)
15-360 Residential Services Capacity Profile
15-365 Community Protection Treatment Worksheet Quarterly Review
15-366 Change of Address
15-376 Skin Observation Protocols
15-379 Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration))
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
15-381 Respite Assessment Worksheet
15-382 Positive Behavior Support Plan (PBSP)
15-383 Functional Behavioral Assessment (FA)
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
15-387 Children’s Respite Application
15-388 Alternative Living Certification Evaluation (Developmental Disabilities Administration)
15-389 Certified Community Residential Services and Support (CCRSS) Initial Application
15-398 Medically Intensive Children's Program (MICP) Application
15-419 Refusal of Services Statement
15-422 No Paid Services Group
15-424 Staffed Residential Cost of Care Adjustment Request
15-429A Notice of Decision on Request for School Break Personal Care Exception to Rule
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
15-436 Request for Adult Family Home Application Fee Waiver
15-447 Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services)
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
15-458 Adult Family Home Notice of Transfer or Change
15-483 Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY
15-492 Medicaid Transformation Project Service Notice
15-493 PASRR Client Referral
15-494 Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration)
15-501 Notification of Initial Assessment Request (Developmental Disabilities Administration)
15-512 Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration)
15-514 Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration)
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
15-516 Companion Home Quarterly Report (Developmental Disabilities Administration)
15-517 Application for Transition from Group Home to Group Training Home
15-547 Continuing Education Event Approval Application (Aging and Long-Term Support Administration)
15-548 Adult Family Home Administrator Training Instructor Application (Home and Community Services)
15-549 Community Instructor Application: DSHS Adult Education (Home and Community Services)
15-550 Community Instructor Application (Home and Community Services)
15-551 Community Instructor Training Program Application and Updates (Home and Community Services)
15-552 Curriculum Approval Application (Home and Community Services)
15-554 Facility Instructor Application (Home and Community Services)
15-555 Facility Training Program Application and Updates (Home and Community Services)
15-556 Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration)
15-558 Adult Family Home (AFH) Resident Significant Change Assessment Request
15-559 Adult Family Home Referral Request (Developmental Disabilities Administration)
15-560 Room Requirements Checklist (Home and Community Services)
15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration)
15-565 Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool
15-567 On-the-Job Facility Training Plan Application and Updates (Home and Community Services)
15-568 DDA Alternative Living Provider Orientation (Developmental Disabilities Administration)
15-569 Notice of Termination of Service (Developmental Disabilities Administration)
15-571 Enhanced Services Facility (ESF) Pre-Inspection Preparation
15-572 Enhanced Services Facility (ESF) Request for Documentation
15-573 Enhanced Services Facility (ESF) Resident List
15-574 Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection
15-575 Enhanced Services Facility (ESF) Resident Interview
15-576 Enhanced Services Facility (ESF) Other Contact Interview
15-577 Enhanced Services Facility (ESF) Environmental Observations
15-578 Enhanced Services Facility (ESF) Resident Record Review
15-579 Enhanced Services Facility (ESF) Staff and Administrative Record Review
15-581 Enhanced Services Facility (ESF) Notes / Worksheets
15-582 Enhanced Services Facility (ESF) Exit Preparation Worksheet
15-583 Enhanced Services Facility (ESF) Food Service Observations and Interviews
15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet
15-585 Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services)
15-585A Enhanced Services Facility (ESF) Staff Schedule Worksheet: 8-hour Shift (Residential Care Services)
15-585B Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services)
15-586 Enhanced Services Facility (ESF) Inspection Packet
15-589 Adult Family Home (AFH) Initial Licensing Inspection (Residential Care Services)
15-589A Adult Family Home (AFH) LIcensing Inspection Floor Plan "Key" (Residential Care Services)
15-589B Adult Family Home (AFH) Licensing: Resident Bedroom / Bathroom Worksheet Continuation (Residential Care Services)
15-589C Adult Family Home (AFH) Relocation Initial Licensing Inspection (Residential Care Services)
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
15-593 21-Day Competency Check Request (Behavioral Health Administration)
15-594 Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration)
15-595 Intensive Habilitation Services (IHS) Behavior Intervention Plan (Developmental Disabilities Administration)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
16-107 Noncustodial Parent's Rights and Responsibilities
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
16-193 Nurse Aide Registry Inquiry (ADSA)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-197 Assisted Living Facility Policies and Procedures Attestation
16-199 New Case/Resource Manager Technology Training Checklist
16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration)
16-202 5-Day Investigation Report (Developmental Disabilities Administration (DDA)
16-202A Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration)
16-203 SIS-A Rating Key (Developmental Disabilities Administration)
16-213 Verification of Legal Status
16-218 Intake Cover Letter to Tribes
16-230 Children's Residential Services
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-235 Photo Release
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
16-242 Ask DSHS
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-244 New Freedom Participant Responsibility Agreement
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-246 Your rights as a client of the Developmental Disabilities Administration
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)
16-262 Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration)
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