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
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
10-595 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