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
10-437 Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility
10-442 Goal Setting and Action Planning Worksheet
10-448 Nurse Delegation (ND) Contract Monitoring Chart Audit (Home and Community Services, Aging and Long Term Support Administration)
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
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-585 Adult Family Home Information Changes
10-596 Comprehensive Functional Assessment of Adult Training Programs
10-601 Assisted Living Facility Information Changes
10-602 Enhanced Services Facility Information Changes
10-603 Nursing Home Information Changes
10-604 Supported Living Information Changes (Residential Care Services)
10-605 ICF / IID Information Changes (Residential Care Services)
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services)
10-613 Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services)
10-614 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services)
10-615 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Representative Interview (Residential Care Services)