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
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-580 Adult Day Services Referral
10-583 DDA PASRR Cover Sheet
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
10-585 Adult Family Home Information Changes
10-591 Assisted Living Facility License Application
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)
10-616 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services)
10-617 Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services)
10-617A Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) General Environment and Safety Worksheet (Residential Care Services)
10-617B Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Client Environment and Safety Worksheet (Residential Care Services)
10-618 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services)
10-619 Certified Community Residential Services and Supports (CCRSS) Staff Background Check and Record Review (Residential Care Services)
10-620 Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services)