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 | |
|---|---|---|---|
| 10-328 | Residential Site Approval Request | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) | ||
| 15-596 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services) | ||
| 06-177 | Residential Training Roster / Reimbursement (Developmental Disabilities Administration) | ||
| 10-635 | Residential Transition Exchange of Information (Developmental Disabilities Administration) | ||
| 15-381 | Respite Assessment Worksheet | ||
| 15-600 | Respite, Stabilization, and Residential Health Center (RHC) Support Referral (Developmental Disabilities Administration) | ||
| 13-899 | Review of Medical Evidence | ||
| 10-348 | Risk Assessment and Community Protection Program Information Checklist | ||
| 05-259 | Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment) | ||
| 10-389 | Room List For Assisted Living Facilities (ALF) | ||
| 15-560 | Room Requirements Checklist (Home and Community Services) | ||
| 05-010 | Rule Exception Request | ||
| 10-427 | School District Communication | ||
| 18-551 | School Statement |
|
|
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) | ||
| 13-954 | Seizure Protocol (Developmental Disabilities Administration) | ||
| 07-098 | Self Employment Monthly Sales and Expense Worksheet |
|
|
| 14-155 | Senior Citizens Service Application | ||
| 11-142 | Service Delivery Outcome Plan: Pre-ETS IL Skills Training | ||
| 11-123 | Service Delivery Outcome Plan: WBL - Experience A | ||
| 11-124 | Service Delivery Outcome Plan: WBL - Experience B | ||
| 11-125 | Service Delivery Outcome Plan: WBL - Experience C | ||
| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 11-097 | Service Delivery Outcome Report (Independent Living Services - IL) |
