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
10-678 Stabilization, Assessment, and Intervention Facility (SAIF) Program Evaluation (Developmental Disabilities Administration)
10-679 Alternative Living Provider Application, Contracting, and Certification Overview Checklist (Developmental Disabilities Administration)
10-680 Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-681 Group Training Home (GTH) Certified Community Residential Services and Supports (CCRSS) Packet (Aging and Long-Term Support Administration)
10-682 Intensive Habilitation Services (IHS) Habilitation Plan (Developmental Disabilities Administration)
10-683 Enhanced Services Facility (ESF) Follow-Up (Residential Care Services)
10-685 Companion Home Provider Supplemental Information (Developmental Disabilities Administration)
10-687 DDA Specialty Adult Family Home (AFH) Pilot: Strengths, Abilities, Interests, Learn (SAIL) (Developmental Disabilities Administration)
10-688 DDA Specialty Adult Family Home (AFH) Pilot Monthly Client Goal and Progress Report (Developmental Disabilities Administration)
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-690 Nursing Care Consultant Transition Tool (Developmental Disabilities Administration)
10-691 Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services)
10-695 Adult Family Home (AFH) Initial Inspection Preparation Checklist (Residential Care Services)
10-696 Assisted Living Facility Medication Observation Worksheet (Residential Care Services)
10-697 Emergency Transitional Support Services Certification Evaluation (Developmental Disabilities Administration)
11-019 Vocational Information (Division of Vocational Rehabilitation)
11-022 Application for Vocational Rehabilitation Services
11-030 Service Delivery Outcome Report (Community Rehabilitation Program - CRP)
11-034B Basic Food Eligibility Requirements: What You Need to Know
11-058 Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation)
11-066 Assistive Communication Technology Request (Office of Deaf and Hard of Hearing)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-068 Customer Internship Program Internship Application (Division of Vocational Rehabilitation)
11-069 DVR Internship Agreement (Division of Vocational Rehabilitation)
11-070 DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation)