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 | |
|---|---|---|---|
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) | ||
| 11-134 | Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation) | ||
| 11-153 | Governor's Opportunity for Supportive Housing (GOSH) Referral (Home and Community Services) | ||
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 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) | ||
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 13-939 | Residential Care Services (Adult Family Home, Assisted Living Facility, Enhanced Services Facility) Community Programs Infection Prevention and Control (ICP) InspectionTool | ||
| 13-940 | RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services) | ||
| 13-943 | Certified Community Residential Supports and Services (CCRSS) Infection Prevention and Control (IPC) Complaint Investigation Pathway | ||
| 13-945 | RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) | ||
| 14-105 | Interview Appointment for Applicant (Community Services Division) |
|
|
| 14-431A | Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 14-501 | Community Resource Declaration | ||
| 14-521 | Your Rights (Home and Community Services) |
|
|
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) | ||
| 14-547 | Continuing Care Retirement Community (CCRC) Registration Application | ||
| 15-356 | DDA Community Protection Program Chaperone Agreement | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) | ||
| 15-515 | CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration) | ||
| 15-548 | Adult Family Home Administrator Training Instructor Application (Home and Community Services) |
