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(desc) | Form Name | File Format | |
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10-382 | Naturalization Services Pre-Screening | ||
10-389 | Room List For Assisted Living Facilities (ALF) | ||
10-389A | Additional Room List For Assisted Living Facilities (ALF) | ||
10-393 | Cost Estimate Worksheet for Hearing Aids and Services | ||
10-396 | SSI Letter (DDA) | ||
10-400 | Information Request Letter |
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10-403 | Residential Services Providers and County and Count-Contracted Providers (Developmental Disabilities Administration (DDA): Mandatory Reporting of Abuse, Neglect, Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
10-412 | Adult Family Home License Relinquishment Letter | ||
10-413 | Application For Contract For Currently Licensed Assisted Living Facility | ||
10-415 | Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance) | ||
10-417 | Adult Family Home Caregiver Experience Attestation (CEA) | ||
10-422 | Adult Family Home (AFH) Quality Improvement Initial Visit | ||
10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | ||
10-424 | Voluntary Participation Statement (Developmental Disability Administration) |
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10-427 | School District Communication | ||
10-437 | Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility | ||
10-438 | Long-Term Care Partnership (LTCP) Asset Designation | ||
10-442 | Goal Setting and Action Planning Worksheet | ||
10-467 | ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services) | ||
10-468 | HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
10-471 | Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration) | ||
10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
10-481 | Health Action Plan (HAP) | ||
10-486 | Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration) | ||
10-487 | Assisted Living Facility Medication Pass Worksheet - Attachment Q |