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
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-235 Photo Release
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
16-242 Ask DSHS
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-244 New Freedom Participant Responsibility Agreement
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-246 Your rights as a client of the Developmental Disabilities Administration
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)
16-262 Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration)
16-263 Integrated Settings Provider Self-Assessment Residential Settings (Developmental Disabilities Administration)
16-264 Integrated Settings Survey: Residential Settings (Developmental Disabilities Administration)
16-265 Integrated Settings Survey: Other Settings (Developmental Disabilities Administration)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
16-274 Exhibit B: School-to-Work County Mentorship Program Monthly Tracking and Reporting (Division of Vocational Rehabilitation)
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
16-276 Diversion Navigator Interview (Office of Forensic Mental Health Services (OFMHS))
16-278 Exhibit E: School-to-Work Success Story (Division of Vocational Rehabilitation)
16-279 Your Responsibility for Participation Towards Costs of Care at a Youth Transitional Care Facility (Developmental Disabilities Administration)
16-280 Individual Integrated Settings Checklist for Residential Providers
16-282 Independent Informal Dispute Resolution (IIDR) Request (Residential Care Services)