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 | ||
| 01-212 | Nurse Delegation Referral and Communication | ||
| 02-516 | Adult Family Home Resident Personal Belongings Inventory (Residential Care Services) | ||
| 02-528 | Fair Hearing Withdrawal |
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| 02-531 | Native Language Identifier | ||
| 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 | ||
| 02-589 | Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration) | ||
| 02-592 | Application for Approval of Interpreter and Translator Continuing Education Activity | ||
| 02-611 | Statement of Understanding: Mid-Certification Review |
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| 02-615 | Social Services Invoice / Receipt Packet Cover (Home and Community Services) | ||
| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 02-690 | Student Evaluation Summary Report | ||
| 02-691 | Student Class Evaluation | ||
| 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) | ||
| 02-714A | DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services) | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) |
