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
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)
16-205 Personal Emergency Plan Information (Developmental Disabilities Administration (DDA))
16-213 Verification of Legal Status
16-234 Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF)
16-234A Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC))
16-243 Community Services Office (CSO) Compliments and Concerns (Economic Services Administration)
16-245 Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services)
16-246 Your rights as a client of the Developmental Disabilities Administration
16-247 Your Rights and Responsibilities When You Receive MAC or TSOA Services Offered by ALTSA
16-253 For Field Staff Use: Sex Offender Notification to Home Care Agency and Consumer Directed Employer (Home and Community Services)
16-255 For Field Use Only: Sex Offender Notification to Facility (Home and Community Services)
16-262 Individual Integrated Settings Checklist for Residential Providers (Optional) (Developmental Disabilities Administration)
16-265 Integrated Settings Survey: Other Settings (Developmental Disabilities Administration)
16-266 Integrated Settings Survey: Employment or Community Inclusion Settings (Developmental Disabilities Administration)
16-267 Integrated Settings Review for Resource Managers (Developmental Disabilities Administration)
16-273 Nurse Delegation Training for Nursing Assistance and Long Term Care Workers (LTCW) (Developmental Disabilities Administration)
16-274 Exhibit B: School-to-Work County Mentorship Program Monthly Tracking and Reporting (Division of Vocational Rehabilitation)
16-275 Change of Circumstance: Community Behavioral Health Supports (CBHS) / 1915i (Home and Community Services)
16-276 Diversion Navigator Interview (Office of Forensic Mental Health Services (OFMHS))
16-278 Exhibit E: School-to-Work Success Story (Division of Vocational Rehabilitation)