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(asc) File Format
16-246 Your rights as a client of the Developmental Disabilities Administration
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
14-521 Your Rights (Home and Community Services)
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-520 Your DSHS Cash or Food Assistance Benefits
14-113 Your Cash and Food Assistance Rights and Responsibilities
10-276 WTRS Consumer Response (Office of Deaf and Hard of Hearing)
14-381 WorkFirst Individual Responsibility Plan
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
13-919 Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration)
20-334 Washington State Learning Center (LC) New Course Request (Division of Developmental Disabilities)
14-439 Washington State Combined Application Program (WASHCAP) Application
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
14-463 Waiver Transportation Record (DDA)
09-508 Waiver of Statute of Limitations
12-212 Waiver of Administrative Disqualification Hearing (Community Services Division)
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
15-184 Volunteer Chore Service Referral
27-063 Voluntary Placement Services For Youth (Age 18-21)
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
10-424 Voluntary Participation Statement (Developmental Disability Administration)
11-019 Vocational Information (Division of Vocational Rehabilitation)
11-098 Vocational Assessment Worksheet
16-213 Verification of Legal Status
17-299 Vendor Agreement Information (Behavioral Health Administration)
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
18-398A Vendor / Provider Overpayment Notice
14-449 Unmet Need Breakdown
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
18-544 Transmittal of Resident Personal Funds
01-210 Transmittal of Client Funds from the Protective Payee
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
02-586 Temporary Employment Hours Tracking Log
04-446 Tell Us How We are Doing! (Division of Child Support)
14-427 Teen Parent Living Assessment
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
10-632 TB Testing Review for Staff (Aging and Long-Term Support Administration)
10-633 TB Testing Review for Resident (Aging and Long-Term Support Administration)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
10-604 Supported Living Information Changes (Residential Care Services)
11-146 Supported Employment Referral (Economic Services Administration)
14-528 Substance Use Good Cause Appointment Letter (HEN Referral)
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-529 Substance Use Disorder Requirements (ABD / PWA)
11-114 Student Workshop Roster
02-690 Student Evaluation Summary Report
02-691 Student Class Evaluation
14-438 Stop Work
02-611 Statement of Understanding: Mid-Certification Review
18-097 Statement of Resources and Expenses
14-050 Statement of Health, Education, and Employment
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-223 Statement from School
14-224 Statement from Landlord/Manager
10-625 State Task Checklist (Aging and Long-Term Support Administration)
13-935 State Hospital Triage Consultation and Expedited Admission (TCEA) Request
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-626 Staffing Pattern (Aging and Long-Term Support Administration)
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
15-424 Staffed Residential Cost of Care Adjustment Request
10-210 Staff Statement of Qualifications
10-631 Staff Qualification and Background Review (Aging and Long-Term Support Administration)
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
15-379 Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration))
13-936 Stabilization, Assessment, and Intervention Services (SAIF) Eligibility and Referral (Developmental Disabilities Administration)
10-678 Stabilization, Assessment, and Intervention Facility (SAIF) Program Evaluation (Developmental Disabilities Administration)
18-627 SSP Client Overpayment Notice (State Supplementary Program)
14-489 SSIF Introduction Letter
10-396 SSI Letter (DDA)
17-123 Spoken Language Interpreter Service Appointment Record
10-658 Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration)
06-159A Specialized Evaluation and Treatment Provider Invoice
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
14-084 Social Service Referral
18-399 Social Service Incorrect Payment Computation
15-376 Skin Observation Protocols
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-203 SIS-A Rating Key (Developmental Disabilities Administration)
17-155 Sign Language Interpreter Registration
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
11-097 Service Delivery Outcome Report (Independent Living Services - IL)
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-125 Service Delivery Outcome Plan: WBL - Experience C
11-124 Service Delivery Outcome Plan: WBL - Experience B
11-123 Service Delivery Outcome Plan: WBL - Experience A
11-142 Service Delivery Outcome Plan: Pre-ETS IL Skills Training
14-155 Senior Citizens Service Application
07-042B Self-Employment Income Report
05-267 Self-Assessment and Monitoring Tool (Home and Community Services)
07-098 Self Employment Monthly Sales and Expense Worksheet
14-534 SDCP Eligibility Checklist (Home and Community Services)
18-551 School Statement
10-427 School District Communication
03-133 Safety Incident / Close Call Report
05-010 Rule Exception Request
15-560 Room Requirements Checklist (Home and Community Services)
10-389 Room List For Assisted Living Facilities (ALF)
10-574 Roads to Community Living (RCL) Person Centered Transition Planning
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
13-899 Review of Medical Evidence
10-593A Restraint / Support Evaluation Continuation
10-593 Restraint / Support Evaluation
15-381 Respite Assessment Worksheet
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
10-328 Residential Site Approval Request
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
15-360 Residential Services Capacity Profile
05-274 Residential Referral Transition (Developmental Disabilities Administration)
15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration)
17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
17-242 Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration)
10-647 Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration)
10-646 Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration)
10-645 Residential Certification Evaluation Client Interview (Developmental Disabilities Administration)
06-125A Residential Allowance Request / Start Up Costs (Developmental Disabilities Administration)
06-125 Residential Allowance Request / Insufficient Income and Housemate Allowance (Developmental Disabilities Administration)
06-125B Residential Allowance Request / Damage (Developmental Disabilities Administration)
06-125C Residential Allowance Request - Shelter Expense (Developmental Disabilities Administration)
15-447 Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services)
14-493 Requirement to Identify a Representative (Developmental Disabilities Administration)
17-041 Request for Records
17-194 Request for Mental Health Service Information
10-330 Request For Legal Advice
18-701 Request for Income Information for Purposes of Entering or Enforcing a Child Support Order
10-673 Request for ICF/IID or SONF Services at an RHC Administration Application
15-420 Request For ICF / IID or SONF Admission
05-013 Request for Hearing
13-925 Request for Formulary Admission or Deletion (Behavioral Health Administration)
02-556 Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration)
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
14-151 Request for DDA Eligibility Determination
09-520 Request for Conference Board
18-681 Request for Collection of Uninsured Health Care Expenses
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-238 Request for an Administrative Hearing (Residential Care Services)
15-436 Request for Adult Family Home Application Fee Waiver
03-391 Report of Possible Client Assault
17-297 Removal and Transport Directive (Behavioral Health Administration)
27-176 Release of Liability (Developmental Disabilities Administration)
03-077 Release of All Claims
15-419 Refusal of Services Statement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
15-456 RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
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)
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)
02-716 Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration)
13-585A Range of Joint Motion Evaluation Chart
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
06-182 Public Records Customer Experience Survey
10-255 Public Health Nurse (PHN) Summary and Recommendations
06-159 Psychologist and Sex Offender Treatment Provider Invoice
13-865 Psychological / Psychiatric Evaluation
13-851 Psychiatric Referral Summary
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
27-057 Provider Referral Letter for Children's Out-of-Home Services (Developmental Disabilities Administration)
15-384 Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA)
27-124 Provider Owned Housing Memorandum of Understanding Residential Provider Attestation
27-123 Provider Owned Housing Memorandum of Understanding Renter Attestation
15-385 Provider Consent For Use of Restrictive Procedures Requiring an ETP
01-110C Protective Payee Report Continuation
01-110 Protective Payee Report
01-110A Protective Payee Periodic Social Services Report
14-426 Protective Payee Payment Plan, Case Assignment, and Closure Notice
14-453 Protective Payee Decision
14-349 Protective Payee Assessment
02-566 Protected Health Information (PHI) Amendment
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
05-273 Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services)
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
27-115 Privacy Complaint
17-208A PRISM Access Request for Multiple Organizations
13-783 Pressure Injury Assessment and Documentation (Home and Community Services)
17-284 Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
11-106 Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation)
11-107 Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation)
11-112 Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation)
11-110 Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation)
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-321 Pre-Admission Screening and Resident Review (PASRR) Equipment Purchase Request
14-538 Pre-Admission Screening and Resident Review (PASRR) Addendum
15-382 Positive Behavior Support Plan (PBSP)
10-572 Planned Respite Application (Developmental Disabilities Administration)
10-648 Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration)
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
13-021 Physical Evaluation
16-235 Photo Release
00-399 Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services)
00-398 Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services)
09-280B Petition for Modification - Administrative Order
10-629 Pet Record Review (Aging and Long-Term Support Administration)
11-154 Personal Pathway
17-180 Personal Information Release (Economic Services Administration)
16-205 Personal Emergency Plan Information
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
27-096 Permission to Share Documents for Reimbursement of Health Care Expenses
10-509 Pediatric Symptoms Checklist (PSC-17)
27-053 Paternity Information
10-643 PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration)
10-668 PASRR Level 2 Evaluation and Determination (Developmental Disabilities Administration)
15-493 PASRR Client Referral
07-081 Participation Reimbursement
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
07-103A Participant Reimbursement with Interpreter Declaration
10-630 Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration)
10-571 Overnight Planned Respite Services Individualized Agreement
10-639 Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration)
17-294 Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration)
20-333 Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration)
13-920 Outpatient Competency Restoration Program (OCRP) Discharge Summary
10-669 Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations)
15-567 On-the-Job Facility Training Plan Application and Updates (Home and Community Services)
05-248 On-Site Review (Office of Refugee and Immigrant Assistance)
17-238 ODHH Approved Sign Language Interpreter Complaints
13-780 Nursing Services Basic Skin Assessment (Home and Community Services)
13-784 Nursing Services Assessment
06-180 Nursing Services Activity Report for Home and Community Services (HCS)
06-181 Nursing Services Activity Report for AAAs
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-603 Nursing Home Information Changes
27-209 Nursing Home Informal Dispute Resolution Request (Residential Care Services)
10-670 Nursing Home Facility License Application (Aging and Long-Term Support Administration)
15-565 Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool
15-031 Nursing Facility Notice of Action
10-339 Nursing Care Consultant (NCC) Assessment (DDA)
06-123 Nursing Assistant Training and Testing Reimbursement
13-680 Nurse Delegation: Rescinding Delegation
13-893 Nurse Delegation: Request For Additional Units
13-678A Nurse Delegation: PRN Medication
14-484 Nurse Delegation: Nursing Visit
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
13-681 Nurse Delegation: Change in Medical Orders
13-678B Nurse Delegation: Assumption of Delegation
13-678 Page 2 Nurse Delegation: Instructions for Nursing Task
13-678 Page 1 Nurse Delegation: Consent for Delegation Process
01-212 Nurse Delegation Referral and Communication
10-448 Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration)
16-193 Nurse Aide Registry Inquiry (ADSA)
14-491 NSA Representative Checklist forDDA Review
15-483 Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY
15-501 Notification of Initial Assessment Request (Developmental Disabilities Administration)
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
10-378 Notification of Age Ten (10) Eligibility Expiration
10-377 Notification of Age Four (4) Eligibility Expiration-
15-474 Notification of Age 20 Eligibility Expiration
15-473 Notification of Age 18 Eligibility Expiration
14-401A Notification of Address Disclosure Request - Part 2
14-401 Notification of Address Disclosure Request - Part 1
14-402 Notice to Parents (WorkFirst)
15-569 Notice of Termination of Service (Developmental Disabilities Administration)
06-189 Notice of Suspension of Supported Living Services (Developmental Disabilities Administration)
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
15-342 Notice of Exception to Rule Decision
15-429A Notice of Decision on Request for School Break Personal Care Exception to Rule
05-256 Notice of Action Exception to Rule for AFH Daily Rates
05-246 Notice of Action Exception to Rule (Excluding AFH)
14-515 Notice and Finding of Responsibility
27-156 Notice and Consent of Communication via Text
27-177 Notice and Consent of Communication via Text
03-374E Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access)
16-107 Noncustodial Parent's Rights and Responsibilities
14-057B Noncustodial Parent Child Support Enforcement Application
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
18-399A Non-SSPS Client / Provider Overpayment AFRS Coding Computation
14-440 Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing)
13-925B Non-Formulary Drug Use Request for Long-Acting Injectables (LAI) (Behavioral Health Administration)
13-925A Non-Formulary Drug Use Request (Behavioral Health Administration)
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
15-422 No Paid Services Group
10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration)
18-463 New Hire Reporting Methods and Instructions (Division of Child Support)
18-463 New Hire Reporting Methods and Instructions
16-244 New Freedom Participant Responsibility Agreement
16-199 New Case/Resource Manager Technology Training Checklist
16-201 New Case / Resource Manager Assessment (Developmental Disabilities Administration)
10-382 Naturalization Services Pre-Screening
14-495 Naturalization Letter
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
14-467 Mid-Certification Review
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
10-634 Medication Assistant Endorsement (Aging and Long-Term Support Administration)
15-398 Medically Intensive Children's Program (MICP) Application
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
06-173 Medical Evidence Reimbursement
14-144A Medical Disability Decision
14-431 Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration)
15-492 Medicaid Transformation Demonstration Service Notice
05-255 Medicaid Transformation Demonstration Notice of Action Exception to Rule
12-210 Medicaid Provider Fraud Report
27-094 Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration)
10-636 Meaningful Day Monthly Calendar
10-637 Meaningful Activity Plan (MAP) Discovery
27-076 Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
15-553 Long-Term Care Worker Basic Training Enhancement Instructions and Application (Home and Community Services)
10-438 Long-Term Care Partnership (LTCP) Asset Designation
19-074 Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation)
10-505 Limitation Extension Task Explanation
10-504 Limitation Extension Request for Clients Under Age 21
10-506 Limitation Extension Request Checklist
10-503 Limitation Extension Evaluation
10-627 Liability Insurance Review (Aging and Long-Term Support Administration)
14-300 Level One Pre-Admission Screening and Resident Review (PASRR)
05-258 Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
14-550 Job Foundation Application (Developmental Disabilities Administration)
13-927 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
13-928 Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration)
14-473 Inventory for Client and Agency Planning (ICAP) Letter
18-464 Introduction to New Hire Reporting
14-105 Interview Appointment for Applicant (Community Services Division)
11-167 Internship: Employer Evaluation
11-168 Internship: Customer Evaluation
14-503 Interim Assistance Reimbursement Agreement Cover
10-671 Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration)
16-218 Intake Cover Letter to Tribes
10-570 Intake and Referral
10-655 Initial Staff and Family Consultation Plan (Developmental Disabilities Administration)
10-657 Initial Specialized Habilitation Plan (Developmental Disabilities Administration)
18-235 Initial payment (Interim Assistance Reimbursement Authorization)
27-188 Initial Opiate Prescription Informed Consent (Behavioral Health Administration)
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-659 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-660 Initial Community Engagement Plan (Developmental Disabilities Administration)
10-329 Informed Consent for ICAP
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
10-400 Information Request Letter
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-234 Individual with Challenging Support Issues (DDA)
07-097 Individual Provider Planned Action Notice Training / Certification (Home and Community Services)
27-203 Individual Provider (IP) Attestation of Informal Support (Home and Community Services)
15-496 Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration)
15-495 Individual Habilitation Plan (IHP) (Developmental Disabilities Administration)
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
11-165 Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation)
20-330 Incident Report to DDA (Developmental Disabilities Administration)
14-525 Incapacity Review for Medical Care Services
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-605 ICF / IID Information Changes (Residential Care Services)
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
27-147 Housing Modification Property Release Agreement
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
27-192 Home and Community Services (HCS) Resumption of Training Attestation
15-591 High School Home Care Aide Instructor Application (Home and Community Services)
10-481 Health Action Plan (HAP)
13-776 HCS / AAA Nursing Services Referral (Home and Community Services)
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
15-494 Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration)
11-153 Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
10-442 Goal Setting and Action Planning Worksheet
06-171 Funding and Expenditure Data (Tribal)
15-383 Functional Behavioral Assessment (FA)
17-011 Forms and Publications Request
11-152 Forensic Navigator to Inpatient - Referral Information Form (RIF) (Office of Forensic Mental Health Services)
13-926 Forensic (6358) Consultation (Behavioral Health Administration)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)
16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services)
27-089 Fingerprint-Based Background Check Notice
27-059 Fingerprint Appointment
14-068 Financial Statement (Division of Vocational Rehabilitation)
06-186 Financial Solvency Information (Aging and Long-Term Support Administration)
18-555 Financial Information Sheet
07-104 Financial Communication to Social Services
14-443 Financial / Social Services Communication
05-254 Federal Subminimum Wage Certificate Holder
13-713 Fast Track Service Agreement
20-273 Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program
02-528 Fair Hearing Withdrawal
15-555 Facility Training Program Application and Updates (Home and Community Services)
15-554 Facility Instructor Application (Home and Community Services)
10-488 Extended Foster Care Program Consent
10-663 Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration)
07-107 Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration)
14-454 Estate Recovery: Repaying the State for Medical and Long Term Services and Supports
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
14-462 Epilepsy Verification Request (Developmental Disabilities Administration)
10-602 Enhanced Services Facility Information Changes
10-535 Enhanced Services Facility Application
15-580 Enhanced Services Facility (ESF) Training Requirements
15-585 Enhanced Services Facility (ESF) Staff Schedule Worksheet
15-579 Enhanced Services Facility (ESF) Staff and Administrative Record Review
15-578 Enhanced Services Facility (ESF) Resident Record Review
15-573 Enhanced Services Facility (ESF) Resident List
15-575 Enhanced Services Facility (ESF) Resident Interview
15-575 Enhanced Services Facility (ESF) Resident Interview
15-574 Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection
15-572 Enhanced Services Facility (ESF) Request for Documentation
15-571 Enhanced Services Facility (ESF) Pre-Inspection Preparation
15-576 Enhanced Services Facility (ESF) Other Contact Interview
15-581 Enhanced Services Facility (ESF) Notes / Worksheets
15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet
15-586 Enhanced Services Facility (ESF) Inspection Packet
15-583 Enhanced Services Facility (ESF) Food Service Observations and Interviews
15-582 Enhanced Services Facility (ESF) Exit Preparation Worksheet
15-577 Enhanced Services Facility (ESF) Environmental Observations
06-174 Enhanced Rate Proposal
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
14-252 Employment Verification
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)
18-483 Employer Payment Identification Instructions
03-076 Employee Personal Property Damage/Loss Claim
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-416 Eligibility Review for Long Term Services and Supports
14-078 Eligibility Review
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-068 DVR Internship Application (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)
27-175 DVR Additional Contractor Information (Division of Vocational Rehabilitation)
02-714A DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services)
02-714 DSHS Virtual Classroom Training Application (Home and Community Services)
03-509 DSHS Unpaid Intern / Volunteer Application
27-182 DSHS Request for Positive Identification – Thumbprint
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
03-387 DSHS Notice of Privacy Practices for Client Medical Information
14-517 DSHS Letter Requesting Non Work SSN
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
17-253 DSHS Background Check System (BCS) Access Request
17-227 DSHS / HCA Systems Access Request
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
06-172 Domestic Violence Prevention Account
10-353 Documentation Request for Medical Condition and Residual Functional Capacity
15-435 Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration
06-162 Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral
11-149 Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet
12-195 Disqualification Consent Agreement
10-351 Disclosure of Services Required by RCW 18.20.300
14-530 Disability Review
14-332 Disability Assessment
14-432 Direct Deposit Enrollment
18-700 Direct Deposit Authorization
18-682 Detail Sheet – Uninsured Health Care Expenses
18-398B Department of Children, Youth, and Families (DCYF) Client Overpayment Notice
27-208 Declaration to Adult Protective Services
27-155 Declaration on Commercial Purposes
18-433 Declaration of Support Payments (Division of Child Support)
09-693 Declaration of Lawful Custody
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
10-583 DDA PASRR Cover Sheet
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
15-318 DDA Crisis Diversion Bed Referral and Intake Information
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)
15-356 DDA Community Protection Program Chaperone Agreement
27-210 DDA Authorization for Release of Referral Video (Developmental Disabilities Administration)
15-568 DDA Alternative Living Provider Orientation (Developmental Disabilities Administration)
13-738 DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families)
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
11-068 Customer Internship Program Internship Application (Division of Vocational Rehabilitation)
15-552 Curriculum Approval Application (Home and Community Services)
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
10-272 Cross-System Crisis Plan (DDA)
06-124 Cost of Care Adjustment (COCA) (Developmental Disabilities)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
16-202A Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration)
27-043 Contractor Intake
27-044A Contractor Information Update (for existing DSHS contractors)
11-166 Contractor 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)
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
15-547 Continuing Education Event Approval Application (Aging and Long-Term Support Administration)
15-556 Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration)
14-547 Continuing Care Retirement Community (CCRC) Registration Application
15-508 Consent and Service Agreement (Developmental Disabilities Administration)
14-012 Consent
09-989 Confidentiality Statement - Tribal Employee
10-489 Confidential Health Information Consent Agreement
10-349 Comprehensive Regional Review Tool
10-589 Comprehensive Functional Assessment of Recreation
10-590 Comprehensive Functional Assessment of Physical Therapy
10-595 Comprehensive Functional Assessment of Occupational Therapy
10-592 Comprehensive Functional Assessment of Direct Care Independent Living Skills
10-594 Comprehensive Functional Assessment of Communication
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-642 Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services)
27-194 Complimentary Therapies Agreement (Developmental Disabilities Administration)
27-194 Complimentary Therapies Agreement (Developmental Disabilities Administration)
15-516 Companion Home Quarterly Report (Developmental Disabilities Administration)
17-262 Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration)
02-589 Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration)
21-061 Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration)
17-260 Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
09-995 Companion Home Certification Evaluation (Developmental Disabilities Administration)
15-512 Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration)
15-514 Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration)
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
23-045 Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division)
14-501 Community Resource Declaration
11-164 Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation)
15-365 Community Protection Treatment Worksheet Quarterly Review
10-348 Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration)
15-551 Community Instructor Training Program Application and Updates (Home and Community Services)
05-269 Community Instructor Self-Assessment for Contract Renewal and/or for Newly Established Contracts (Home and Community Services)
05-268 Community Instructor Self-Assessment (Home and Community Services)
10-641 Community Instructor Qualification Tool (Home and Community Services)
02-692 Community Instructor Class List Tracking Log
15-549 Community Instructor Application: DSHS Adult Education (Home and Community Services)
15-550 Community Instructor Application (Home and Community Services)
01-218 Community Inclusion Rate Adjustment for Staffed Residential Rate
10-660 Community Engagement 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
14-431A Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration)
05-252 Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation)
14-310 Client Status Change Report
15-358 Client Referral Summary (Developmental Disabilities Administration)
18-398 Client Overpayment Notice
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
14-238 Client Income Report
12-209 Client Fraud Report
21-060 Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment
15-387 Children’s Respite Application
10-649 Children's State Operated Living Alternatives (SOLA) Certification Evaluation (Developmental Disabilities Administration)
21-059 Children's Staffed Residential Quality Assurance Assessment
16-230 Children's Residential Services
14-057D Child Support Referral Continuation
14-057 Child Support Referral
09-741 Child Support Order Review Request
18-607 Child Care Verification
10-471 Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration)
10-244 Child and Family Engagement Plan (Developmental Disabilities)
03-506 Character, Competence, and Suitability Assessment
14-076 Change of Circumstances
05-260 Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment)
15-366 Change of Address
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)
10-621 Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services)
00-410 Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control Assessment (IPC) Pathway (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)
00-413A Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes for COVID-19 (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-622 Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services)
10-617A Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Home Environment and Safety Worksheet
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-677 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review
10-613 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-676 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review
10-619 Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services)
15-389 Certified Community Residential Services and Support (CCRSS) Initial Application
13-917 CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
15-515 CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration)
05-272 Case Manager Instructions Following a Hearing Decision
10-360 Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B
17-300 BHA Personal Information Release (Behavioral Health Administration)
13-712 Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration)
27-109 BCCU Applicant Affidavit
07-103 Basic Food Employment and Training (BFET) Participant Reimbursement
11-034B Basic Food Eligibility Requirements: What You Need to Know
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
02-573 Background check Identification Verification (Office of Deaf and Hard of Hearing)
09-653 Background Check Authorization
18-484 Automatic Payment Authorization and Electronic Funds Transfer Information
14-532 Authorized Representative
17-211 Authorization for SSI Facilitation Records (Economic Services Administration)
09-415 Authorization for Expenditure (Non-Employee)
27-130 Authorization for Alternate EBT Cardholder
17-063 Authorization
11-066 Assistive Communication Technology Request (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)