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.
| Number(desc) | Form Name | File Format | |
|---|---|---|---|
| 02-740 | Private Duty Nursing (PDN) Time Log for the Month of (Home and Community Services) | ||
| 02-743 | Community Instructor Training Report (Home and Community Services) | ||
| 02-744 | DSHS Remote Skills Training Application: Virtual Classroom (Home and Community Services) | ||
| 02-751 | Accommodations / Modifications Request | ||
| 02-753 | Facility Virtual Classroom Training Application and Attestation (Home and Community Services) | ||
| 02-754 | High School Home Care Aide Student Evaluation Summary Report (Home and Community Services) | ||
| 02-755 | High School Home Care Aide Student Class Evaluation (Home and Community Services) | ||
| 02-756 | High School Home Care Aide Class List Tracking Log (Home and Community Services) | ||
| 03-076 | Employee Personal Property Damage/Loss Claim | ||
| 03-077 | Release of All Claims | ||
| 03-374B | Agreement on Nondisclosure of Confidential Information - Non-Employee | ||
| 03-374D | ESA Non-Dislcosure of Confidential Information Agreement - Non Employee | ||
| 03-374E | Nondisclosure of Confidential Information Agreement for Non-Employee (eJAS Access) | ||
| 03-387 | DSHS Notice of Privacy Practices for Client Medical Information |
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| 03-387A | DSHS Notice of Privacy Practices for Client Medical Information with Acknowledgement |
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| 03-387B | DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs |
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| 03-389A | Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790) | ||
| 03-391 | Report of Possible Client Assault | ||
| 03-490 | Employee / Contractor Awareness IRS Safeguard Training Certification | ||
| 03-506 | Character, Competence, and Suitability Assessment | ||
| 03-509 | DSHS Unpaid Intern / Volunteer Application | ||
| 04-449 | Participants Feedback (Domestic Violence Intervention Treatment) | ||
| 04-449A | Survivors Feedback (Domestic Violence Intervention Treatment) | ||
| 04-452 | DSHS Community Services Survey (Community Services Division, Economic Services Administration) |
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| 04-452A | DSHS Community Services Customer Survey (Community Services Division) |
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