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
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)
15-601 New Freedom (NF) Notice of Exception to Rule (ETR) Decision (Goods and Services)
15-602 Enhanced Services Facility (ESF) Monitoring Visit (Residential Care Services)
16-072 NonAssistance Support Enforcement Information (Division of Child Support)
16-172 Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration
16-182 Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration)
16-195 Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative
16-202 5-Day Investigation Report (Developmental Disabilities Administration (DDA)
16-202A Corrective Action Plan (Developmental Disabilities Administration)