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
11-019 Vocational Information (Division of Vocational Rehabilitation)
10-424 Voluntary Participation Statement (Developmental Disability Administration)
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
15-184 Volunteer Chore Service Referral
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
12-212 Waiver of Administrative Disqualification Hearing (Community Services Division)
09-508 Waiver of Statute of Limitations
14-463 Waiver Transportation Record (DDA)
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
14-439 Washington State Combined Application Program (WASHCAP) Application
20-334 Washington State Learning Center (LC) New Course Request (Division of Developmental Disabilities)
13-919 Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration)
13-928 Withdrawal of Petition for Conditional Release or Unconditional Release (Behavioral Health Administration)
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-133 Work Related Injury / Close Call Report
14-381 WorkFirst Individual Responsibility Plan
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-520 Your DSHS Cash or Food Assistance Benefits
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-521 Your Rights (Home and Community Services)
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-246 Your rights as a client of the Developmental Disabilities Administration