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
09-693 Declaration of Lawful Custody
09-728 Washington State Addendum to Box 2 of Part B - Plan Administrator Response
09-741 Child Support Order Review Request
09-995 Companion Home Certification Evaluation (Developmental Disabilities Administration)
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-210 Staff Statement of Qualifications
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
10-231 Adult Family Home (AFH) Referral Checklist (DDA)
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-244 Child and Family Engagement Plan (Developmental Disabilities)
10-255 Public Health Nurse (PHN) Summary and Recommendations
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
10-268 Pre-Placement Agreement (Developmental Disabilities Administration)
10-269 Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration)
10-269A Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration)
10-270 Assisted Living Facility Admission Agreement(s) Attestation
10-272 Cross-System Crisis Plan (DDA)
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-301 Notification of Eligibility Review (Developmental Disabilities Administration)
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
10-328 Residential Site Approval Request