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 | |
|---|---|---|---|
| 15-552 | Curriculum Approval Application (Home and Community Services) | ||
| 27-143 | CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool | ||
| 10-272 | Cross-System Crisis Plan (DDA) | ||
| 15-318 | Crisis Diversion Bed Referral and Intake Information (Developmental Disabilities Administration) | ||
| 06-124 | Cost of Care Adjustment (COCA) (Developmental Disabilities) | ||
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
| 10-393A | Cost Estimate Worksheet for Cochlear Implants (Division of Vocational Rehabilitation) | ||
| 10-393B | Cost Estimate Worksheet for Bone Anchored "Hearing Aid" Auditory Devices (BAHA) (Division of Vocational Rehabilitation) | ||
| 16-202A | Corrective Action Plan (Developmental Disabilities Administration) | ||
| 27-044A | Contractor Information Update (for existing DSHS contractors) | ||
| 17-266 | Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation) | ||
| 11-084 | Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation) | ||
| 10-415 | Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance) | ||
| 14-544 | Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment) | ||
| 15-547 | Continuing Education Event Approval Application (Aging and Long-Term Support Administration) | ||
| 15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
| 14-547 | Continuing Care Retirement Community (CCRC) Registration Application | ||
| 27-222 | Consent to Release and/or Use Confidential Information for Completing an Adult Home License Application | ||
| 14-012 | Consent |
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| 10-489 | Confidential Health Information Consent Agreement |
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| 10-558A | Condensed Resident / Representative Interview (Residential Care Services) | ||
| 10-558 | Comprehensive Resident / Representative Interview (Residential Care Services) | ||
| 10-349 | Comprehensive Regional Review Tool | ||
| 10-596 | Comprehensive Functional Assessment of Adult Training Programs | ||
| 10-642 | Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services) |
