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.
| Number | Form Name(asc) | File Format | |
|---|---|---|---|
| 10-670 | Nursing Home Facility License Application (Aging and Long-Term Support Administration) | ||
| 15-031 | Nursing Facility Notice of Action | ||
| 10-690 | Nursing Care Consultant Transition Tool (Developmental Disabilities Administration) | ||
| 10-713 | Nursing Care Consultant (NCC) Focused Assessment (Developmental Disabilities Administration) | ||
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | ||
| 06-123 | Nursing Assistant Training and Testing Reimbursement | ||
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 14-484 | Nurse Delegation: Nursing Visit | ||
| 10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 16-273 | Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration) | ||
| 01-212 | Nurse Delegation Referral and Communication | ||
| 16-193 | Nurse Aide Registry Inquiry (ADSA) | ||
| 14-491 | NSA Representative Checklist forDDA Review | ||
| 10-301 | Notification of Enrollment Review (Developmental Disabilities Administration) |
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| 15-290 | Notification of Annual Assessment Review and Person Centered Services Planning Meeting | ||
| 10-377 | Notification of Age Four (4) Enrollment Expiration- |
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| 14-401A | Notification of Address Disclosure Request - Part 2 | ||
| 14-401 | Notification of Address Disclosure Request - Part 1 | ||
| 14-402 | Notice to Parents (WorkFirst) |
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