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.
| Number | Form Name(desc) | File Format | |
|---|---|---|---|
| 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 | ||
| 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 |
