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.

Choose search option and begin typing the form #
Keyword Search
Number Form Name(asc) File Format
10-362 Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A
16-197 Assisted Living Facility Policies and Procedures Attestation
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-696 Assisted Living Facility Medication Observation Worksheet (Residential Care Services)
10-591 Assisted Living Facility License Application
10-601 Assisted Living Facility Information Changes
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-270 Assisted Living Facility Admission Agreement(s) Attestation
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
15-274 Assistance Available Schedule (DDA)
27-189 Asset Verification Authorization (Home and Community Services)
14-492 Assessment Meeting Wrap-up
16-242 Ask DSHS
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool