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
13-940 RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services)
13-941 RCS (AFH, ALF, ESF) Infection Prevention and Control (IPC) Complaint Investigation Tool (Residential Care Services)
13-942 CCRSS Infection Prevention and Control (IPC) Complaint Investigation Tool (Residential Care Services)
13-943 Certified Community Residential Supports and Services (CCRSS) Infection Prevention and Control (IPC) Complaint Investigation Pathway
13-944 RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility)
13-945 RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services)
14-001 Application for Cash or Food Assistance
14-012 Consent
14-050 Statement of Health, Education, and Employment
14-057 Child Support Referral
14-057B Noncustodial Parent Child Support Enforcement Application
14-057D Child Support Referral Continuation
14-068 Financial Statement (Division of Vocational Rehabilitation)
14-076 Change of Circumstances
14-078 Eligibility Review
14-084 Social Service Referral
14-105 Interview Appointment for Applicant (Community Services Division)
14-113 Your Cash and Food Assistance Rights and Responsibilities
14-144A Medical Disability Decision
14-151 Request for DDA Eligibility Determination
14-155 Senior Citizens Service Application
14-223 Statement from School
14-224 Statement from Landlord/Manager
14-225 Acknowledgement of Services
14-252 Employment Verification