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 | |
|---|---|---|---|
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 13-021 | Physical Evaluation | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-645 | Adult Family Home Injuries and Accidents Log | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-692A | Assisted Living Facility (ALF) Dementia Screening Tool | ||
| 13-712 | Behavioral Health Wraparound Support (BHWS) Request (Aging and Long-Term Support Administration (ALTSA) | ||
| 13-713 | Fast Track Service Agreement |
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| 13-738 | DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families) | ||
| 13-776 | HCS / AAA Nursing Services Referral (Home and Community Services) | ||
| 13-780 | Nursing Services Basic Skin Assessment (Home and Community Services) | ||
| 13-783 | Pressure Injury Assessment and Documentation (Home and Community Services) | ||
| 13-784 | Nursing Services Assessment | ||
| 13-851 | Psychiatric Referral Summary | ||
| 13-865 | Psychological / Psychiatric Evaluation | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-899 | Review of Medical Evidence | ||
| 13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | ||
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 13-911 | DDA Nursing Service Referral (Developmental Disabilities Administration) |
