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
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 (Developmental Disabilities Administration)
06-199 Specialized Evaluation and Consultation Quarterly Report (Developmental Disabilities Administration) n
06-159 Specialized Evaluation and Consultation Provider Invoice (Developmental Disabilities Administration)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
16-191 SOLA Vehicle Trip Log (Developmental Disabilities Administration)
02-615 Social Services Invoice / Receipt Packet Cover (Home and Community Services)
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)
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
07-098 Self Employment Monthly Sales and Expense Worksheet
14-534 SDCP Eligibility Checklist (Home and Community Services)