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(desc) | File Format | |
|---|---|---|---|
| 13-944 | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) | ||
| 13-940 | RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services) | ||
| 13-941 | RCS (AFH, ALF, ESF) Infection Prevention and Control (IPC) Complaint Investigation Tool (Residential Care Services) | ||
| 13-945 | RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 16-286 | RCS Nursing Home Pre-Occupancy Inspection Follow-Up Site Visit (Residential Care Services) | ||
| 16-285 | RCS Nursing Home Pre-Occupancy Inspection Site Visit – Initial Findings (Residential Care Services) | ||
| 10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) | ||
| 15-419 | Refusal of Services Statement | ||
| 06-200 | Registered Nurse (RN) Delegation Billing | ||
| 03-077 | Release of All Claims | ||
| 27-176 | Release of Liability (Developmental Disabilities Administration) | ||
| 17-297 | Removal and Transport Directive (Behavioral Health Administration) | ||
| 03-391 | Report of Possible Client Assault | ||
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 10-238 | Request for an Administrative Hearing (Residential Care Services) | ||
| 10-277 | Request for Children's Out-of-Home Services (Developmental Disabilities Administration) | ||
| 18-681 | Request for Collection of Uninsured Health Care Expenses | ||
| 09-520 | Request for Conference Board |
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| 14-151 | Request for DDA Eligibility Determination |
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| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
| 13-925 | Request for Formulary Admission or Deletion (Behavioral Health Administration) | ||
| 05-013 | Request for Hearing |
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| 18-701 | Request for Income Information for Purposes of Entering or Enforcing a Child Support Order | ||
| 17-194 | Request for Mental Health Service Information |
