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(desc) | Form Name | File Format | |
|---|---|---|---|
| 01-110 | Protective Payee Report | ||
| 01-110A | Protective Payee Periodic Social Services Report | ||
| 01-110C | Protective Payee Report Continuation | ||
| 01-205 | Able Bodied Adults Without Dependents (ABAWD) Activity Report | ||
| 01-210 | Transmittal of Client Funds from the Protective Payee | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration) | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 02-586 | Temporary Employment Hours Tracking Log | ||
| 02-592 | Application for Approval of Interpreter and Translator Continuing Education Activity | ||
| 02-611 | Statement of Understanding: Mid-Certification Review |
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| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 02-690 | Student Evaluation Summary Report | ||
| 02-692 | Community Instructor Class List Tracking Log | ||
| 02-709 | Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration) | ||
| 02-714 | Community Instructors Virtual Classroom Training Application (Home and Community Services) | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 02-740 | Office of Justice and Civil Rights Complaint Request |
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| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 02-743 | Community Instructor Training Report (Home and Community Services) | ||
| 02-754 | High School Home Care Aide Student Evaluation Summary Report (Home and Community Services) | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | ||
| 03-077 | Release of All Claims | ||
| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee |
