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 | |
|---|---|---|---|
| 17-041 | Request for Records |
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| 10-709 | Request for Residential Habilitation for Dependent Youth Services (Developmental Disabilities Administration) | ||
| 11-192 | Request to Provide CRP-IL Services and Background Check: Create Account (Division of Vocational Rehabilitation) | ||
| 11-193 | Request to Provide CRP-IL Services and Background Check: Update Account (Division of Vocational Rehabilitation) | ||
| 14-493 | Requirement to Identify a Representative (Developmental Disabilities Administration) | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 10-551 | Resident List (Residential Care Services) | ||
| 10-557 | Resident Medication Review (Residential Care Services) | ||
| 10-555 | Resident Observations (Residential Care Services) | ||
| 10-556 | Resident Record Review (Residential Care Services) | ||
| 06-125B | Residential Allowance Request - Damages (Developmental Disabilities Administration) | ||
| 06-125C | Residential Allowance Request - Shelter Expense (Developmental Disabilities Administration) | ||
| 06-125A | Residential Allowance Request - Start Up Costs (Developmental Disabilities Administration) | ||
| 06-125 | Residential Allowance Request / Insufficient Income (Developmental Disabilities Administration) | ||
| 13-939 | Residential Care Services (Adult Family Home, Assisted Living Facility, Enhanced Services Facility) Community Programs Infection Prevention and Control (ICP) InspectionTool | ||
| 10-563 | Residential Care Services Notes (Residential Care Services) | ||
| 15-494 | Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration) | ||
| 27-247 | Residential Habilitation for Dependent Agreement for Youth (Age 18-20) (Developmental Disabilities Administration) | ||
| 10-707 | Residential Habilitation for Dependent Youth (RHDY) Engagement Plan (Developmental Disabilities Administration) | ||
| 27-248 | Residential Habilitation for Dependent Youth Acknowledgement (Developmental Disabilities Administration) | ||
| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 10-666 | Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration) | ||
| 15-564 | Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) | ||
| 15-360 | Residential Services Capacity Profile | ||
| 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 |
