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.
| Number | Form Name(asc) | File Format | |
|---|---|---|---|
| 06-200 | Registered Nurse (RN) Delegation Billing | ||
| 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 | ||
| 13-945 | RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) | ||
| 13-941 | RCS (AFH, ALF, ESF) Infection Prevention and Control (IPC) Complaint Investigation Tool (Residential Care Services) | ||
| 13-940 | RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services) | ||
| 13-944 | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes (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) | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
| 13-865 | Psychological / Psychiatric Evaluation | ||
| 13-851 | Psychiatric Referral Summary | ||
| 10-232 | Provider Referral Letter For Residential 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 |
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| 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 |
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| 14-453 | Protective Payee Decision | ||
| 14-349 | Protective Payee Assessment |
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