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
14-527 Substance Use Disorder Requirements (HEN Referral Program)
14-529 Substance Use Disorder Requirements (ABD / PWA)
02-759 Subleased Housing Memorandum of Understanding Residential Provider Attestation (Developmental Disabilities Administration)
02-758 Subleased Housing Memorandum of Understanding Renter Attestation (Developmental Disabilities Administration)
02-690 Student Evaluation Summary Report
02-691 Student Class Evaluation
14-438 Stop Work
02-611 Statement of Understanding: Mid-Certification Review
18-097 Statement of Resources and Expenses
14-050 Statement of Health, Education, and Employment
14-436 Statement of Adult Acting in Loco Parentis (As a Parent)
14-223 Statement from School
14-224 Statement from Landlord/Manager
10-625 State Task Checklist (Aging and Long-Term Support Administration)
13-935 State Hospital Triage Consultation and Expedited Admission (TCEA) Request
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-626 Staffing Pattern (Aging and Long-Term Support Administration)
10-326 Staffed Residential Rate Proposal (Developmental Disabilities Administration)
10-326A Staffed Residential Home DCYF Billing
15-424 Staffed Residential Cost of Care Adjustment Request
10-210 Staff Statement of Qualifications
10-631 Staff Qualification and Background Review (Aging and Long-Term Support Administration)
10-552 Staff List (Residential Care Services)
10-561 Staff Interview (Residential Care Services)
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)