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
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
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
15-501 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
10-377 Notification of Age Four (4) 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 or Unencrypted Email
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