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.

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Number(desc) Form Name File Format
14-552 TED Program Pilot Project: Application for Emergency Alerting Device KIT (Office of the Deaf and Hard of Hearing)
14-553 High School Home Care Aide Training Program and Instructor Application and Updates (Aging and Long-Term Support Administration)
14-554 Household Application for Sun Bucks
15-031 Nursing Facility Notice of Action
15-184 Volunteer Chore Service Referral
15-215 AFH Quality Improvement Visit Assessment
15-274 Assistance Available Schedule (DDA)
15-290 Notification of Annual Assessment Review and Person Centered Services Planning Meeting
15-291 Person Centered Service Planning and Annual Assessment Meeting
15-295 Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration)
15-304 HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration)
15-314 Client Necessary Supplemental Accommodation Representative Requirement Checklist
15-318 DDA Crisis Diversion Bed Referral and Intake Information
15-331 Annual Assessment Checklist (Developmental Disability Administration)
15-342 Notice of Exception to Rule Decision
15-344 Private Duty Nursing Logs and Skilled Nursing Tasks Log
15-356 DDA Community Protection Program Chaperone Agreement
15-358 Client Referral Summary (Developmental Disabilities Administration)
15-360 Residential Services Capacity Profile
15-365 Community Protection Treatment Worksheet Quarterly Review
15-376 Skin Observation Protocols
15-379 Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration))
15-380 Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration)
15-381 Respite Assessment Worksheet
15-382 Positive Behavior Support Plan (PBSP)