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
10-389A Additional Room List For Assisted Living Facilities (ALF)
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-393A Cost Estimate Worksheet for Cochlear Implants (Division of Vocational Rehabilitation)
10-393B Cost Estimate Worksheet for Bone Anchored "Hearing Aid" Auditory Devices (BAHA) (Division of Vocational Rehabilitation)
10-400 Information Request Letter
10-403 Residential Services Providers and County and Count-Contracted Providers (Developmental Disabilities Administration (DDA): Mandatory Reporting of Abuse, Neglect, Exploitation, or Abandonment of a Child or Vulnerable Adult
10-413 Application For Contract For Currently Licensed Assisted Living Facility
10-415 Contract Monitoring Checklist On-Site Review (Office of Refugee and Immigrant Assistance)
10-423 Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services
10-424 Voluntary Participation Statement (Developmental Disability Administration)
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-442 Goal Setting and Action Planning Worksheet
10-468 HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults
10-472 Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration)
10-486 Assisted Living Facility Food Service Observations - Attachment P (Residential Care Facilities, Aging and Long-Term Support Administration)
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-489 Confidential Health Information Consent Agreement
10-501 Referral to DSHS for Basic Food Employment and Training (BFET)
10-504 Limitation Extension Request for Clients Under Age 21
10-508 Adult Family Home Disclosure of Services Required by RCW 70.128.280
10-549 Inspection Process and Records Request (Residential Care Services)
10-550 Entrance Information and Observation (Residential Care Services)
10-556 Resident Record Review (Residential Care Services)
10-559 Administrative Records Review (Residential Care Services)
10-559A Administrative Records Review Continuation (Residential Care Services)