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
10-210 Staff Statement of Qualifications
10-232 Provider Referral Letter For Residential Services (Developmental Disabilities Administration)
10-234 Individual with Challenging Support Issues (DDA)
10-234A Individual with Complex Behaviors (Aging and Long-Term Support Administration)
10-237 Nursing Home Transfer or Discharge Notice (Residential Care Services)
10-238 Request for an Administrative Hearing (Residential Care Services)
10-269 Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration)
10-269A Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration)
10-277 Request for Children's Out-of-Home Services (Developmental Disabilities Administration)
10-301 Notification of Enrollment Review (Developmental Disabilities Administration)
10-329 Informed Consent for ICAP
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
10-334 Monitoring of Side Effects Scale (MOSES) (DDA)
10-337 Important Information for SSP Recipients and Their Payees (DDA)
10-348 Risk Assessment and Community Protection Program Information Checklist
10-351 Disclosure of Services Required by RCW 18.20.300
10-353 Documentation Request for Medical Condition and Residual Functional Capacity
10-360 Assisted Living Facility Request for Documentation - Attachment B
10-366 Assisted Living Facility Other Contact Interview - Attachment H
10-368 Assisted Living Facility Resident Record Review - Attachment J
10-369 Assisted Living Facility Staff Sample / Record Review - Attachment K
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-377 Notification of Age Four (4) Enrollment Expiration-
10-389 Room List For Assisted Living Facilities (ALF)