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(asc) | File Format | |
|---|---|---|---|
| 10-422 | Adult Family Home (AFH) Quality Improvement Initial Visit | ||
| 15-590 | Adult Family Home (AFH) Quality Assurance Visit (Residential Care Services) | ||
| 10-650A | Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services) | ||
| 02-709 | Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) | ||
| 15-589B | Adult Family Home (AFH) Licensing: Resident Bedroom / Bathroom Worksheet Continuation (Residential Care Services) | ||
| 15-589A | Adult Family Home (AFH) LIcensing Inspection Floor Plan "Key" (Residential Care Services) | ||
| 10-575 | Adult Family Home (AFH) Inspection Packet (Residential Care Services) | ||
| 15-589 | Adult Family Home (AFH) Initial Licensing Inspection (Residential Care Services) | ||
| 10-695 | Adult Family Home (AFH) Initial Inspection Preparation Checklist (Residential Care Services) | ||
| 27-179 | Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services) | ||
| 21-065 | Adult Family Home (AFH) Emergency Evacuation Drill | ||
| 16-277 | Adult Family Home (AFH) Confirmation Letter (Residential Care Services) | ||
| 06-184 | Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services) | ||
| 10-580 | Adult Day Services Referral | ||
| 14-299 | Adult Assessment Referral (Economic Services Administration) | ||
| 10-559A | Administrative Records Review Continuation (Residential Care Services) | ||
| 10-559B | Administrative Records Review - Former Staff and Others with Unsupervised Access (Residential Care Services) | ||
| 10-559 | Administrative Records Review (Residential Care Services) | ||
| 18-176 | Address Release Information Letter | ||
| 18-176A | Address Release Information Letter |
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| 10-389A | Additional Room List For Assisted Living Facilities (ALF) | ||
| 05-261 | Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment) | ||
| 05-262 | Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment) | ||
| 27-207 | Acknowledgement Statement (Meaningful Day) (Home and Community Services) | ||
| 14-225 | Acknowledgement of Services |
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