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
10-362A Assisted Living Facility Resident Characteristic Roster and Sample Selection Addendum - Attachment D
10-363 Assisted Living Facility Resident Group Meeting - Attachment E
10-365 Assisted Living Facility Resident Interview - Attachment G
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-367 Assisted Living Facility Environmental Observations - Attachment I
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-372 Assisted Living Facility Contract Requirements - Attachment N
10-377 Notification of Age Four (4) Enrollment Expiration-
10-382 Naturalization Services Pre-Screening
10-389 Room List For Assisted Living Facilities (ALF)
10-389A Additional Room List For Assisted Living Facilities (ALF)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-396 SSI Letter (DDA)
10-400 Information Request Letter
10-403 Residential Services Providers and County and Count-Contracted Providers (Developmental Disabilities Administration (DDA): Mandatory Reporting of Abuse, Neglect, Exploitation, or Abandonment of a Child or Vulnerable Adult
10-412 Adult Family Home License Relinquishment Letter
10-413 Application For Contract For Currently Licensed Assisted Living Facility
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
10-417 Adult Family Home Caregiver Experience Attestation (CEA)
10-422 Adult Family Home (AFH) Quality Improvement Initial Visit
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-424 Voluntary Participation Statement (Developmental Disability Administration)