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.
| Number(desc) | Form Name | File Format | |
|---|---|---|---|
| 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) | ||
| 10-700 | CCRSS Follow-Up Visit (Certified Community Residential Services and Supports, Residential Care Services.) | ||
| 10-707 | Residential Habilitation for Dependent Youth (RHDY) Engagement Plan (Developmental Disabilities Administration) | ||
| 10-708 | Planning for Youth Aged 18-21 Receiving RHDY Services (Developmental Disabilities Administration) | ||
| 10-709 | Request for Residential Habilitation for Dependent Youth Services (Developmental Disabilities Administration) | ||
| 11-022 | Application for Vocational Rehabilitation Services |
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| 11-030 | Service Delivery Outcome Report (Community Rehabilitation Program - CRP) | ||
| 11-058 | Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) | ||
| 11-066 | Assistive Communication Technology Request (Office of Deaf and Hard of Hearing) |
