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
18-551 School Statement
10-427 School District Communication
05-010 Rule Exception Request
15-560 Room Requirements Checklist (Home and Community Services)
10-389 Room List For Assisted Living Facilities (ALF)
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
13-899 Review of Medical Evidence
15-381 Respite Assessment Worksheet
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)
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
15-494 Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (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)