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(desc) Form Name File Format
02-740 Office of Justice and Civil Rights Complaint Request
02-743 Community Instructor Training Report (Home and Community Services)
02-744 DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services)
02-752 Accommodations / Modifications Request
03-076 Employee Personal Property Damage/Loss Claim
03-077 Release of All Claims
03-133 Work Related Injury / Close Call Report
03-374B Agreement on Nondisclosure of Confidential Information - Non-Employee
03-374D ESA Non-Dislcosure of Confidential Information Agreement - Non Employee
03-374E Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access)
03-387 DSHS Notice of Privacy Practices for Client Medical Information
03-387A DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement
03-387B DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs
03-389A Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790)
03-391 Report of Possible Client Assault
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-506 Character, Competence, and Suitability Assessment
03-509 DSHS Unpaid Intern / Volunteer Application
04-449 Participants Feedback (Domestic Violence Intervention Treatment)
04-449A Survivors Feedback (Domestic Violence Intervention Treatment)
04-452 DSHS Community Services Survey (Community Services Division, Economic Services Administration)
04-452A DSHS Community Services Customer Survey (Community Services Division)
05-010 Rule Exception Request
05-013 Request for Hearing
05-246 Notice of Action Exception to Rule (Excluding AFH)