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)
06-191 DPI College Financial Aid Request (Division of Program Integrity)
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, PWA, and HEN Referral Substance Use Disorder Treatment Verification
01-205 Able Bodied Adults Without Dependents (ABAWD) Activity Report
02-751 Accommodations / Modifications Request
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
10-559 Administrative Records Review (Residential Care Services)
10-559B Administrative Records Review - Former Staff and Others with Unsupervised Access (Residential Care Services)
10-559A Administrative Records Review Continuation (Residential Care Services)
14-299 Adult Assessment Referral (Economic Services Administration)
10-580 Adult Day Services Referral
06-184 Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services)
16-277 Adult Family Home (AFH) Confirmation Letter (Residential Care Services)
21-065 Adult Family Home (AFH) Emergency Evacuation Drill