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 | |
|---|---|---|---|
| 15-554 | Facility Instructor Application (Home and Community Services) | ||
| 15-556 | Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration) | ||
| 15-564 | Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) | ||
| 15-568 | DDA Alternative Living Provider Orientation (Developmental Disabilities Administration) | ||
| 15-569 | Notice of Termination of Service (Developmental Disabilities Administration) | ||
| 15-572 | Enhanced Services Facility (ESF) Request for Documentation | ||
| 15-576 | Enhanced Services Facility (ESF) Other Contact Interview | ||
| 15-578 | Enhanced Services Facility (ESF) Resident Record Review | ||
| 15-579 | Enhanced Services Facility (ESF) Staff and Administrative Record Review | ||
| 15-581 | Enhanced Services Facility (ESF) Notes / Worksheets | ||
| 15-582 | Enhanced Services Facility (ESF) Exit Preparation Worksheet | ||
| 15-584 | Enhanced Services Facility (ESF) Medication Pass Worksheet | ||
| 15-585 | Enhanced Services Facility (ESF) Staff Schedule Worksheet (Residential Care Services) | ||
| 15-585A | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 8-hour Shift (Residential Care Services) | ||
| 15-585B | Enhanced Services Facility (ESF) Staff Schedule Worksheet: 12-hour Shift (Residential Care Services) | ||
| 15-589A | Adult Family Home (AFH) LIcensing Inspection Floor Plan "Key" (Residential Care Services) | ||
| 15-589B | Adult Family Home (AFH) Licensing: Resident Bedroom / Bathroom Worksheet Continuation (Residential Care Services) | ||
| 15-591 | High School Home Care Aide Instructor Application (Home and Community Services) | ||
| 15-593 | 21-Day Competency Check Request (Behavioral Health Administration) | ||
| 15-595 | Children's Behavior Intervention Plan (Developmental Disabilities Administration) | ||
| 15-596 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services) | ||
| 15-599 | Early Engagement of Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 15-600 | Respite, Stabilization, and Residential Health Center (RHC) Support Referral (Developmental Disabilities Administration) | ||
| 16-072 | NonAssistance Support Enforcement Information (Division of Child Support) |
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| 16-172 | Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration |
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