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
10-558A Condensed Resident / Representative Interview (Residential Care Services)
10-489 Confidential Health Information Consent Agreement
14-012 Consent
27-222 Consent to Release and/or Use Confidential Information for Completing an Adult Home License Application
14-547 Continuing Care Retirement Community (CCRC) Registration Application
15-556 Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration)
15-547 Continuing Education Event Approval Application (Aging and Long-Term Support Administration)
14-544 Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment)
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
11-084 Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation)
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)
27-044A Contractor Information Update (for existing DSHS contractors)
16-202A Corrective Action Plan (Developmental Disabilities Administration)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
06-124 Cost of Care Adjustment (COCA) (Developmental Disabilities)
10-272 Cross-System Crisis Plan (DDA)
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
15-552 Curriculum Approval Application (Home and Community Services)
11-068 Customer Internship Program Internship Application (Division of Vocational Rehabilitation)
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
13-738 DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families)
15-568 DDA Alternative Living Provider Orientation (Developmental Disabilities Administration)
27-210 DDA Authorization for Release of Referral Video (Developmental Disabilities Administration)
15-356 DDA Community Protection Program Chaperone Agreement
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)