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(asc) File Format
07-098 Self Employment Monthly Sales and Expense Worksheet
14-534 SDCP Eligibility Checklist (Home and Community Services)
18-551 School Statement
10-427 School District Communication
05-010 Rule Exception Request
15-560 Room Requirements Checklist (Home and Community Services)
10-389 Room List For Assisted Living Facilities (ALF)
05-259 Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment)
10-348 Risk Assessment and Community Protection Program Information Checklist
13-899 Review of Medical Evidence
15-600 Respite, Stabilization, and Residential Health Center (RHC) Support Referral (Developmental Disabilities Administration)
15-381 Respite Assessment Worksheet
10-635 Residential Transition Exchange of Information (Developmental Disabilities Administration)
06-177 Residential Training Roster / Reimbursement (Developmental Disabilities Administration)
15-596 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services)
11-130 Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services)
10-328 Residential Site Approval Request
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
15-360 Residential Services Capacity Profile
15-564 Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
02-632 Residential Provider's Report of Weapon Ownership in Residential Setting
27-248 Residential Habilitation for Dependent Youth Acknowledgement (Developmental Disabilities Administration)
10-707 Residential Habilitation for Dependent Youth (RHDY) Engagement Plan (Developmental Disabilities Administration)
27-247 Residential Habilitation for Dependent Agreement for Youth (Age 18-20) (Developmental Disabilities Administration)