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
10-650 Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-650A Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services)
10-653 State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application
10-656 Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration)
10-658 Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-660 Community Engagement Quarterly Progress Report (Developmental Disabilities Administration)
10-661 Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-662 Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration)
10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration)
10-666 Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration)
10-669 Out-of-Home Services (OHS) Transition Checklist (Developmental Disabilities Administrations)
10-670 Nursing Home Facility License Application (Aging and Long-Term Support Administration)
10-671 Intensive Habilitation Services for Children Certification Evaluation (Developmental Disabilities Administration)
10-676 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Finances Record Review
10-677 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Record Review
10-680 Certified Community Residential Services and Supports (CCRSS) Group Home (GH) / Client Home Team Coordinator Packet (Residential Care Services)
10-685 Companion Home Provider Supplemental Information (Developmental Disabilities Administration)
10-688 DDA Specialty Adult Family Home (AFH) Pilot Monthly Client Goal and Progress Report (Developmental Disabilities Administration)
10-689 Assisted Living Facility Monitoring Visit (Residential Care Services)
10-691 Certified Community Residential Services and Supports (CCRSS) Client Characteristics (Residential Care Services)
10-692 Group Training Home (GTH) Team Coordinator (TC) Packet (Residential Care Services)
10-696 Assisted Living Facility Medication Observation Worksheet (Residential Care Services)
10-697 Emergency Transitional Support Services Certification Evaluation (Developmental Disabilities Administration)
10-698 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Administrator Record Review and Interview (Residential Care Services)
10-699 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Exit Preparation / Exit Conference (Residential Care Services)