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
10-269 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 Eligibility 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
10-373 Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O
10-377 Notification of Age Four (4) Eligibility Expiration-
10-389 Room List For Assisted Living Facilities (ALF)
10-389A Additional Room List For Assisted Living Facilities (ALF)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-400 Information Request Letter
10-403 Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult
10-413 Application For Contract For Currently Licensed Assisted Living Facility