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(desc) File Format
16-269 Adult Family Home No One Home Letter (Residential Care Services)
15-458 Adult Family Home Notice of Transfer or Change
27-223 Adult Family Home Policies and Procedures Attestation
16-268 Adult Family Home Post-Licensing Instructions (Residential Care Services)
15-559 Adult Family Home Referral Request (Developmental Disabilities Administration)
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
14-551 Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application
10-711 Adult Family Homes Program Training Plan (Residential Care Services)
27-178 Adult Protective Services (APS) Administrative Hearing Request
06-188 Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration)
05-249 Adult Residential Care Services Notice of a Change
09-052 Affidavit of Forged Endorsement
06-169 AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services)
06-168 AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services)
10-638 AFH Meaningful Day - Monthly Activities and Challenging Behavior Log
15-215 AFH Quality Improvement Visit Assessment
14-478 Aged, Blind, or Disabled (ABD) Program Medical Treatment Participation
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
17-116 AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion
15-388 Alternative Living Certification Evaluation (Developmental Disabilities Administration)
10-665 Alternative Living Provider Application (Developmental Disabilities Administration)
10-679 Alternative Living Provider Application, Contracting, and Certification Overview Checklist (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)
10-467 ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services)