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
02-755 High School Home Care Aide Student Class Evaluation (Home and Community Services)
02-754 High School Home Care Aide Student Evaluation Summary Report (Home and Community Services)
14-553 High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration)
10-644 Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA)
14-554 Household Application for Sun Bucks
27-147 Housing Modification Property Release Agreement
18-334 How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs
10-605 ICF / IID Information Changes (Residential Care Services)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
27-147A In-Home Environmental Adaptations General Utility and Repair Property Release Agreement (Aging and Long-Term Support Administration)
14-525 Incapacity Review for Medical Care Services
20-330 Incident Report to DDA (Developmental Disabilities Administration)
16-282 Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services)
11-165 Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation)
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
16-280 Individual Integrated Settings Checklist for Residential Providers
16-262 Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration)
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-258 Individual With Possible Community Protection Issues (Developmental Disabilities Administration)
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
13-915 Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration)
10-400 Information Request Letter
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)