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
11-192 Request to Provide CRP-IL Services and Background Check: Create Account (Division of Vocational Rehabilitation)
11-193 Request to Provide CRP-IL Services and Background Check: Update Account (Division of Vocational Rehabilitation)
12-212 Waiver of Administrative Disqualification Hearing (Community Services Division)
13-585A Range of Joint Motion Evaluation Chart
13-678B Nurse Delegation: Assumption of Delegation
13-899 Review of Medical Evidence
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration)
13-928 Withdrawal of Petition for Conditional Release or Unconditional Release (Behavioral Health Administration)
14-050 Statement of Health, Education, and Employment
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-225 Acknowledgement of Services
14-401 Notification of Address Disclosure Request - Part 1
14-401A Notification of Address Disclosure Request - Part 2
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-459 Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration)
14-460 Notice of Insufficient Information (Developmental Disabilities Administration)
14-465 Sources for Eligibility Information (Developmental Disabilities Administration)
14-475 Appointment Letter for Division of Child Support (DCS) Good Cause Determination
14-514 Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center
14-515 Notice and Finding of Responsibility
14-535 Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration)
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
15-031 Nursing Facility Notice of Action
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting