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
11-163 Applicant Certification and Assurances (Division of Vocational Rehabilitation)
15-593 21-Day Competency Check Request (Behavioral Health Administration)
16-202 5-Day Investigation Report (Developmental Disabilities Administration (DDA)
11-132 90 Day Review (Division of Vocational Rehabilitation)
17-226 AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration)
14-541 ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents)
14-526 ABD and HEN Referral Substance Use Treatment Verification
01-205 Able Bodied Adults Without Dependents (ABAWD) Activity Report
14-225 Acknowledgement of Services
27-207 Acknowledgement Statement (Meaningful Day) (Home and Community Services)
05-262 Add or Remove a Service 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)
10-389A Additional Room List For Assisted Living Facilities (ALF)
18-176 Address Release Information Letter
18-176A Address Release Information Letter
14-299 Adult Assessment Referral (Economic Services Administration)
10-580 Adult Day Services Referral
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)
06-184 Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services)
21-065 Adult Family Home (AFH) Emergency Evacuation Drill
27-179 Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services)
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)
02-709 Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration)
10-650A Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-231 Adult Family Home (AFH) Referral Checklist (DDA)
15-589C Adult Family Home (AFH) Relocation Initial Licensing Inspection (Residential Care Services)
15-558 Adult Family Home (AFH) Resident Significant Change Assessment Request
15-548 Adult Family Home Administrator Training Instructor Application (Home and Community Services)
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
15-449 Adult Family Home Disclosure of Charges Required by RCW 70.128.280
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-585 Adult Family Home Information Changes
13-645 Adult Family Home Injuries and Accidents Log
10-412 Adult Family Home License Relinquishment Letter
27-226 Adult Family Home Management Agreement: Attestation Information and Attachments (Residential Care Services)
15-458 Adult Family Home Notice of Transfer or Change
27-223 Adult Family Home Policies and Procedures Attestation
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
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
10-232A AFH / ARC Provider Referral Letter
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)
15-331 Annual Assessment Checklist (Developmental Disability Administration)
27-110 Applicant Request for a Copy of Background Check Information
19-237 Application Budget Summary (Residential Care Services)
02-592 Application for Approval of Interpreter and Translator Continuing Education Activity
14-001 Application for Cash or Food Assistance
10-413 Application For Contract For Currently Licensed Assisted Living Facility
12-207 Application for Disaster Cash Assistance
12-206 Application for Disaster Food Benefits
14-542 Application for New Program Certification (Domestic Violence Intervention Treatment)
18-078 Application for Nonassistance Support Enforcement Services
14-543 Application for Renewal Program Certification (Domestic Violence Intervention Treatment)
14-264 Application for Telecommunications Equipment
15-517 Application for Transition from Group Home to Group Training Home
11-022 Application for Vocational Rehabilitation Services
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool
16-242 Ask DSHS
14-492 Assessment Meeting Wrap-up
27-189 Asset Verification Authorization (Home and Community Services)
15-274 Assistance Available Schedule (DDA)
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-601 Assisted Living Facility Information Changes
10-591 Assisted Living Facility License Application
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-366 Assisted Living Facility Other Contact Interview - Attachment H
16-197 Assisted Living Facility Policies and Procedures Attestation
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
10-360 Assisted Living Facility Request for Documentation - Attachment B
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
10-361 Assisted Living Facility Resident List - Attachment C
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
17-292 Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
17-063 Authorization
27-130 Authorization for Alternate EBT Cardholder
09-415 Authorization for Expenditure (Non-Employee)
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
14-532 Authorized Representative
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
09-653 Background Check Authorization
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
11-034B Basic Food Eligibility Requirements: What You Need to Know
07-103 Basic Food Employment and Training (BFET) Participant Reimbursement
27-109 BCCU Applicant Affidavit
13-712 Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration)
17-300 BHA Personal Information Release (Behavioral Health Administration)
05-272 Case Manager Instructions Following a Hearing Decision
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
15-389 Certified Community Residential Services and Support (CCRSS) Initial Application
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
10-676 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-677 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (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)
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-691 Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services)
10-617A Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (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)
00-413 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Tool for COVID-19 (Residential Care Services)
00-410 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
10-680 Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
15-366 Change of Address
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
14-076 Change of Circumstances
03-506 Character, Competence, and Suitability Assessment
10-244 Child and Family Engagement Plan (Developmental Disabilities)
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
18-607 Child Care Verification
09-741 Child Support Order Review Request
14-057 Child Support Referral
14-057D Child Support Referral Continuation
16-230 Children's Residential Services
21-059 Children's Staffed Residential Quality Assurance Assessment
10-649 Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration)
15-387 Children’s Respite Application
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment
12-209 Client Fraud Report
14-238 Client Income Report
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
18-398 Client Overpayment Notice
15-358 Client Referral Summary (Developmental Disabilities Administration)
14-310 Client Status Change Report
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
10-660 Community Engagement Quarterly Progress Report (Developmental Disabilities Administration)
01-218 Community Inclusion Rate Adjustment for Staffed Residential Rate
15-550 Community Instructor Application (Home and Community Services)
15-549 Community Instructor Application: DSHS Adult Education (Home and Community Services)
02-692 Community Instructor Class List Tracking Log
10-641 Community Instructor Qualification 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)
15-551 Community Instructor Training Program Application and Updates (Home and Community Services)
10-348 Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration)
15-365 Community Protection Treatment Worksheet Quarterly Review
11-164 Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation)
10-613 Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services)
14-501 Community Resource Declaration
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
15-514 Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration)
15-512 Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration)
09-995 Companion Home Certification Evaluation (Developmental Disabilities Administration)
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
17-260 Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration)
21-061 Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration)
02-589 Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration)
17-262 Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration)
10-685 Companion Home Provider Supplemental Information (Developmental Disabilities Administration)
15-516 Companion Home Quarterly Report (Developmental Disabilities Administration)
27-194 Complimentary Therapies Agreement (Developmental Disabilities Administration)
27-194 Complimentary Therapies Agreement (Developmental Disabilities Administration)
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-594 Comprehensive Functional Assessment of Communication
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-590 Comprehensive Functional Assessment of Physical Therapy
10-589 Comprehensive Functional Assessment of Recreation
10-349 Comprehensive Regional Review Tool
10-489 Confidential Health Information Consent Agreement
09-989 Confidentiality Statement - Tribal Employee
14-012 Consent
27-222 Consent to Release and/or Use Confidential Information for Completing an Adult Home License Application
14-547 Continuing Care Retirement Community (CCRC) Registration Application
15-556 Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration)
15-547 Continuing Education Event Approval Application (Aging and Long-Term Support Administration)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)
27-044A Contractor Information Update (for existing DSHS contractors)
16-202A Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
06-124 Cost of Care Adjustment (COCA) (Developmental Disabilities)
10-272 Cross-System Crisis Plan (DDA)
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
15-552 Curriculum Approval Application (Home and Community Services)
11-068 Customer Internship Program Internship Application (Division of Vocational Rehabilitation)
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
13-738 DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families)
15-568 DDA Alternative Living Provider Orientation (Developmental Disabilities Administration)
27-210 DDA Authorization for Release of Referral Video (Developmental Disabilities Administration)
15-356 DDA Community Protection Program Chaperone Agreement
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)
15-318 DDA Crisis Diversion Bed Referral and Intake Information
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
10-688 DDA Specialty Adult Family Home (AFH) Pilot Monthly Client Goal and Progress Report (Developmental Disabilities Administration)
10-687 DDA Specialty Adult Family Home (AFH) Pilot: Strengths, Abilities, Interests, Learn (SAIL) (Developmental Disabilities Administration)
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
27-219 Death Notification Checklist for Medical Providers (Developmental Disabilities Administration)
27-218 Death Notification Checklist for Residential Habilitation Center (RHC) Staff (Developmental Disabilities Administration)
09-693 Declaration of Lawful Custody
18-433 Declaration of Support Payments (Division of Child Support)
27-155 Declaration on Commercial Purposes
27-208 Declaration to Adult Protective Services
18-398B Department of Children, Youth, and Families (DCYF) Client Overpayment Notice
18-682 Detail Sheet – Uninsured Health Care Expenses
18-700 Direct Deposit Authorization
14-432 Direct Deposit Enrollment
14-332 Disability Assessment
14-530 Disability Review
10-351 Disclosure of Services Required by RCW 18.20.300
11-180 Discovery Profile Report (Developmental Disabilities Administration)
27-220 Disposition of Remains / Release of Body Permit (Developmental Disabilities Administration)
12-195 Disqualification Consent Agreement
11-149 Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
10-353 Documentation Request for Medical Condition and Residual Functional Capacity
06-172 Domestic Violence Prevention Account
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
17-227 DSHS / HCA Systems Access Request
17-253 DSHS Background Check System (BCS) Access Request
27-225 DSHS Claim of Stolen EBT Benefits: Food (Community Services Division)
04-452A DSHS Community Services Customer Survey (Community Services Division)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
14-517 DSHS Letter Requesting Non Work SSN
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
27-182 DSHS Request for Positive Identification – Thumbprint
03-509 DSHS Unpaid Intern / Volunteer Application
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)
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
14-078 Eligibility Review
14-416 Eligibility Review for Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-076 Employee Personal Property Damage/Loss Claim
18-483 Employer Payment Identification Instructions
27-081 Employment and Day Program Services Providers: Mandatory Reporting of Abuse, Improper Use of Restraint, Neglect, Personal or Financial Exploitation, Abandonment of a Child or Vulnerable Adult (Developmental Disability Administration)
14-252 Employment Verification
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
06-174 Enhanced Rate Proposal
15-577 Enhanced Services Facility (ESF) Environmental Observations
15-582 Enhanced Services Facility (ESF) Exit Preparation Worksheet
10-683 Enhanced Services Facility (ESF) Follow-Up (Residential Care Services)
15-583 Enhanced Services Facility (ESF) Food Service Observations and Interviews
15-586 Enhanced Services Facility (ESF) Inspection Packet
15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet
15-581 Enhanced Services Facility (ESF) Notes / Worksheets
15-576 Enhanced Services Facility (ESF) Other Contact Interview
15-571 Enhanced Services Facility (ESF) Pre-Inspection Preparation
15-572 Enhanced Services Facility (ESF) Request for Documentation
15-574 Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection
15-575 Enhanced Services Facility (ESF) Resident Interview
15-573 Enhanced Services Facility (ESF) Resident List
15-578 Enhanced Services Facility (ESF) Resident Record Review
15-579 Enhanced Services Facility (ESF) Staff and Administrative Record Review
15-585 Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services)
15-585B Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services)
15-585A Enhanced Services Facility (ESF) Staff Schedule Worksheet: 8-hour Shift (Residential Care Services)
10-535 Enhanced Services Facility Application
10-602 Enhanced Services Facility Information Changes
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
10-663 Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration)
10-488 Extended Foster Care Program Consent
15-554 Facility Instructor Application (Home and Community Services)
15-555 Facility Training Program Application and Updates (Home and Community Services)
02-528 Fair Hearing Withdrawal
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
13-713 Fast Track Service Agreement
05-254 Federal Subminimum Wage Certificate Holder
14-443 Financial / Social Services Communication
07-104 Financial Communication to Social Services
18-555 Financial Information Sheet
06-186 Financial Solvency Information (Aging and Long-Term Support Administration)
14-068 Financial Statement (Division of Vocational Rehabilitation)
27-059 Fingerprint Appointment
27-089 Fingerprint-Based Background Check Notice
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)
13-926 Forensic (6358) Consultation (Behavioral Health Administration)
11-152 Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services)
17-011 Forms and Publications Request
15-383 Functional Behavioral Assessment (FA)
06-171 Funding and Expenditure Data (Tribal)
10-442 Goal Setting and Action Planning Worksheet
11-153 Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
10-681 Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
10-481 Health Action Plan (HAP)
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
14-553 High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration)
27-192 Home and Community Services (HCS) Resumption of Training Attestation
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
27-147 Housing Modification Property Release Agreement
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
10-605 ICF / IID Information Changes (Residential Care Services)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
14-525 Incapacity Review for Medical Care Services
20-330 Incident Report to DDA (Developmental Disabilities Administration)
11-165 Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation)
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
16-262 Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration)
27-203 Individual Provider (IP) Attestation of Informal Support (Home and Community Services)
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration)
10-400 Information Request Letter
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
10-329 Informed Consent for ICAP
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
27-188 Initial Opiate Prescription Informed Consent (Behavioral Health Administration)
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
10-657 Initial Specialized Habilitation Plan (Developmental Disabilities Administration)
10-655 Initial Staff and Family Consultation Plan (Developmental Disabilities Administration)
10-570 Intake and Referral
16-218 Intake Cover Letter to Tribes
16-263 Integrated Settings Provider Self-Assessment Residential Settings (Developmental Disabilities Administration)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-265 Integrated Settings Survey: Other Settings (Developmental Disabilities Administration)
16-264 Integrated Settings Survey: Residential Settings (Developmental Disabilities Administration)
15-595 Intensive Habilitation Services (IHS) Behavior Intervention Plan (Developmental Disabilities Administration)
10-682 Intensive Habilitation Services (IHS) Habilitation Plan (Developmental Disabilities Administration)
13-917 Intensive Habilitation Services (IHS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
10-671 Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration)
14-503 Interim Assistance Reimbursement Agreement Cover
11-168 Internship: Customer Evaluation
11-167 Internship: Employer Evaluation
14-105 Interview Appointment for Applicant (Community Services Division)
18-464 Introduction to New Hire Reporting
14-473 Inventory for Client and Agency Planning (ICAP) Letter
13-927 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
13-928 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
14-550 Job Foundation Application (Developmental Disabilities Administration)
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
10-503 Limitation Extension Evaluation
10-506 Limitation Extension Request Checklist
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
10-438 Long-Term Care Partnership (LTCP) Asset Designation
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-637 Meaningful Activity Plan (MAP) Discovery
10-636 Meaningful Day Monthly Calendar
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
12-210 Medicaid Provider Fraud Report
05-255 Medicaid Transformation Project Notice of Action Exception to Rule
15-492 Medicaid Transformation Project Service Notice
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
14-144A Medical Disability Decision
06-173 Medical Evidence Reimbursement
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
15-398 Medically Intensive Children's Program (MICP) Application
10-634 Medication Assistant Endorsement (Aging and Long-Term Support Administration)
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
14-467 Mid-Certification Review
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
14-495 Naturalization Letter
10-382 Naturalization Services Pre-Screening
16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration)
16-199 New Case/Resource Manager Technology Training Checklist
27-043 New Contractor Intake
16-244 New Freedom Participant Responsibility Agreement
18-463 New Hire Reporting Methods and Instructions (Division of Child Support)
10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration)
15-422 No Paid Services Group
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
13-925A Non-Formulary Drug Use Request (Behavioral Health Administration)
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
14-057B Noncustodial Parent Child Support Enforcement Application
16-107 Noncustodial Parent's Rights and Responsibilities
03-374E Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access)
27-156 Notice and Consent of Communication via Text
27-177 Notice and Consent of Communication via Unencrypted Email
14-515 Notice and Finding of Responsibility
05-246 Notice of Action Exception to Rule (Excluding AFH)
05-256 Notice of Action Exception to Rule for AFH Daily Rates
15-429A Notice of Decision on Request for School Break Personal Care Exception to Rule
15-342 Notice of Exception to Rule Decision
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration)
15-569 Notice of Termination of Service (Developmental Disabilities Administration)
14-402 Notice to Parents (WorkFirst)
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
10-377 Notification of Age Four (4) Eligibility Expiration-
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
15-501 Notification of Initial Assessment Request (Developmental Disabilities Administration)
15-483 Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY
14-491 NSA Representative Checklist forDDA Review
16-193 Nurse Aide Registry Inquiry (ADSA)
10-448 Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration)
01-212 Nurse Delegation Referral and Communication
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
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
13-681 Nurse Delegation: Change in Medical Orders
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
14-484 Nurse Delegation: Nursing Visit
13-678A Nurse Delegation: PRN Medication
13-893 Nurse Delegation: Request For Additional Units
13-680 Nurse Delegation: Rescinding Delegation
06-123 Nursing Assistant Training and Testing Reimbursement
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
10-690 Nursing Care Consultant Transition Tool (Developmental Disabilities Administration)
15-031 Nursing Facility Notice of Action
15-565 Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool
10-670 Nursing Home Facility License Application (Aging and Long-Term Support Administration)
27-209 Nursing Home Informal Dispute Resolution Request (Residential Care Services)
10-603 Nursing Home Information Changes
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
06-181 Nursing Services Activity Report for AAAs
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
13-784 Nursing Services Assessment
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
17-238 ODHH Approved Sign Language Interpreter Complaints
02-740 Office of Justice and Civil Rights Complaint Request
05-248 On-Site Review (Office of Refugee and Immigrant Assistance)
15-567 On-the-Job Facility Training Plan Application and Updates (Home and Community Services)
10-669 Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations)
27-063 Out-of-Home Services Agreement for Youth (Age 18-21) (Developmental Disabilities Administration)
13-920 Outpatient Competency Restoration Program (OCRP) Discharge Summary
20-333 Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration)
17-294 Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration)
10-639 Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration)
10-571 Overnight Planned Respite Services Individualized Agreement
10-630 Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration)
07-103A Participant Reimbursement with Interpreter Declaration
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
07-081 Participation Reimbursement
15-493 PASRR Client Referral
10-668 PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration)
10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration)
27-053 Paternity Information
10-509 Pediatric Symptoms Checklist (PSC-17)
27-096 Permission to Share Documents for Reimbursement of Health Care Expenses
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-291 Person Centered Service Planning and Annual Assessment Meeting
17-180 Personal Information Release (Economic Services Administration)
11-154 Personal Pathway
10-629 Pet Record Review (Aging and Long-Term Support Administration)
09-280B Petition for Modification - Administrative Order
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)
16-235 Photo Release
13-021 Physical Evaluation
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-648 Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration)
10-572 Planned Respite Application (Developmental Disabilities Administration)
15-382 Positive Behavior Support Plan (PBSP)
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
17-321 Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
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)
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
17-284 Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing)
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
17-208A PRISM Access Request for Multiple Organizations
27-115 Privacy Complaint
15-594 Private Duty Nursing (PDN) Care Plan (Aging and Long-Term Services Administration)
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
05-273 Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services)
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
02-566 Protected Health Information (PHI) Amendment
14-349 Protective Payee Assessment
14-453 Protective Payee Decision
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
01-110A Protective Payee Periodic Social Services Report
01-110 Protective Payee Report
01-110C Protective Payee Report Continuation
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
27-057 Provider Referral Letter for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
13-851 Psychiatric Referral Summary
13-865 Psychological / Psychiatric Evaluation
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
13-585A Range of Joint Motion Evaluation Chart
02-716 Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration)
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)
00-412 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)
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
15-419 Refusal of Services Statement
06-200 Registered Nurse (RN) Delegation Billing
03-077 Release of All Claims
27-176 Release of Liability (Developmental Disabilities Administration)
17-297 Removal and Transport Directive (Behavioral Health Administration)
03-391 Report of Possible Client Assault
15-436 Request for Adult Family Home Application Fee Waiver
10-238 Request for an Administrative Hearing (Residential Care Services)
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
18-681 Request for Collection of Uninsured Health Care Expenses
09-520 Request for Conference Board
14-151 Request for DDA Eligibility Determination
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
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration)
05-013 Request for Hearing
10-673 Request for ICF/IID or SONF Services at an RHC Administration Application
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
17-194 Request for Mental Health Service Information
17-041 Request for Records
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
15-447 Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services)
06-125B Residential Allowance Request - Damages (Developmental Disabilities Administration)
06-125C Residential Allowance Request - Shelter Expense (Developmental Disabilities Administration)
06-125A Residential Allowance Request - Start Up Costs (Developmental Disabilities Administration)
06-125 Residential Allowance Request / Insufficient Income (Developmental Disabilities Administration)
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)
15-494 Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration)
05-274 Residential Referral Transition (Developmental Disabilities Administration)
15-360 Residential Services Capacity Profile
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-328 Residential Site Approval Request
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
15-381 Respite Assessment Worksheet
13-899 Review of Medical Evidence
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
10-389 Room List For Assisted Living Facilities (ALF)
15-560 Room Requirements Checklist (Home and Community Services)
05-010 Rule Exception Request
03-133 Safety Incident / Close Call Report
10-427 School District Communication
18-551 School Statement
14-534 SDCP Eligibility Checklist (Home and Community Services)
07-098 Self Employment Monthly Sales and Expense Worksheet
05-267 Self-Assessment and Monitoring Tool (Home and Community Services)
07-042B Self-Employment Income Report
14-155 Senior Citizens Service Application