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
11-022 Application for Vocational Rehabilitation Services
14-341 Application to Convert Payment Services Only (PSO) Case to Full Collection Services
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
20-332 Appropriate Level of Forensic Services (ALFS) Screening Tool
16-242 Ask DSHS
14-492 Assessment Meeting Wrap-up
27-189 Asset Verification Authorization (Home and Community Services)
15-274 Assistance Available Schedule (DDA)
06-176 Assisted Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms
13-692A Assisted Living Facility (ALF) Dementia Screening Tool
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-601 Assisted Living Facility Information Changes
10-591 Assisted Living Facility License Application
10-696 Assisted Living Facility Medication Observation Worksheet (Residential Care Services)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-366 Assisted Living Facility Other Contact Interview - Attachment H
16-197 Assisted Living Facility Policies and Procedures Attestation
10-359 Assisted Living Facility Pre Inspection Preparation - Attachment A