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(desc) File Format
15-599 Early Engagement of Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services)
14-078 Eligibility Review
14-416 Eligibility Review for Long Term Services and Supports
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
10-697 Emergency Transitional Support Services Certification Evaluation (Developmental Disabilities Administration)
10-640 Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services)
03-490 Employee / Contractor Awareness IRS Safeguard Training Certification
03-076 Employee Personal Property Damage/Loss Claim
18-483 Employer Payment Identification Instructions
14-252 Employment Verification
11-121 Enhanced Case Management Referral Consideration (Developmental Disabilities Administration)
10-701 Enhanced Respite Services School Notification (Developmental Disabilities Administration)
15-577 Enhanced Services Facility (ESF) Environmental Observations
15-582 Enhanced Services Facility (ESF) Exit Preparation Worksheet
10-683 Enhanced Services Facility (ESF) Follow-Up (Residential Care Services)
15-583 Enhanced Services Facility (ESF) Food Service Observations and Interviews
15-586 Enhanced Services Facility (ESF) Inspection Packet
15-584 Enhanced Services Facility (ESF) Medication Pass Worksheet
15-602 Enhanced Services Facility (ESF) Monitoring Visit (Residential Care Services)
15-581 Enhanced Services Facility (ESF) Notes / Worksheets
15-576 Enhanced Services Facility (ESF) Other Contact Interview
15-571 Enhanced Services Facility (ESF) Pre-Inspection Preparation
15-572 Enhanced Services Facility (ESF) Request for Documentation
15-574 Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection
15-575 Enhanced Services Facility (ESF) Resident Interview