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
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
14-427 Teen Parent Living Assessment
27-215 Teleservice Agreement (Developmental Disabilities Administration)
02-586 Temporary Employment Hours Tracking Log
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
13-906 Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services)
17-345 Transitional Care Management Exchange of Information (Developmental Disability Administration)
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
01-210 Transmittal of Client Funds from the Protective Payee
18-544 Transmittal of Resident Personal Funds
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
10-628 Trust Fund Review (Aging and Long-Term Support Administration)
14-449 Unmet Need Breakdown
18-398A Vendor / Provider Overpayment Notice
09-013 Vendor Affidavit of Lost, Stolen, or Destroyed Warrant
17-299 Vendor Agreement Information (Behavioral Health Administration)
16-213 Verification of Legal Status
11-098 Vocational Assessment Worksheet
10-424 Voluntary Participation Statement (Developmental Disability Administration)
09-004C Voluntary Placement Agreement for Child or Youth with Developmental Disabilities
15-184 Volunteer Chore Service Referral
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)