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
10-481 Health Action Plan (HAP)
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-488 Extended Foster Care Program Consent
10-489 Confidential Health Information Consent Agreement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-503 Limitation Extension Evaluation
10-504 Limitation Extension Request for Clients Under Age 21
10-505 Limitation Extension Task Explanation
10-506 Limitation Extension Request Checklist
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-509 Pediatric Symptoms Checklist (PSC-17)
10-535 Enhanced Services Facility Application
10-570 Intake and Referral
10-571 Overnight Planned Respite Services Individualized Agreement
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-580 Adult Day Services Referral
10-583 DDA PASRR Cover Sheet
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-585 Adult Family Home Information Changes
10-591 Assisted Living Facility License Application