Electronic DSHS Forms

The Electronic DSHS Forms page is a centralized repository where the public can find and download official forms for Washington Department of Social and Health Services programs.

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 Form File
09-995 Companion Home Certification Evaluation (Home and Community Living Administration)
10-104B Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration)
10-210 Staff Statement of Qualifications
10-217 Nurse Delegation: Nursing Assistant Credentials and Training
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-244 Child and Family Engagement Plan (Developmental Disabilities)