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(asc) Form Name File Format
15-356 DDA Community Protection Program Chaperone Agreement
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-342 Notice of Exception to Rule Decision
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
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
15-274 Assistance Available Schedule (DDA)
15-215 AFH Quality Improvement Visit Assessment
15-184 Volunteer Chore Service Referral
15-031 Nursing Facility Notice of Action
14-554 Household Application for Sun Bucks
14-553 High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration)
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
14-551 Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application
14-550 Job Foundation Application (Developmental Disabilities Administration)
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)