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 | |
|---|---|---|---|
| 11-164 | Community Rehabilitation Program (CRP) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-165 | Independent Living (IL) Services and Qualifications (Division of Vocational Rehabilitation) | ||
| 11-180 | Discovery Profile Report (Division of Vocational Rehabilitation) | ||
| 11-192 | Request to Provide CRP-IL Services and Background Check: Create Account (Division of Vocational Rehabilitation) | ||
| 11-193 | Request to Provide CRP-IL Services and Background Check: Update Account (Division of Vocational Rehabilitation) | ||
| 12-008 | Basic Food Affidavit Replacement for Household Disaster |
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| 12-206 | Application for Disaster Food Benefits | ||
| 12-207 | Application for Disaster Cash Assistance | ||
| 12-209 | Client Fraud Report | ||
| 12-210 | Medicaid Provider Fraud Report | ||
| 12-212 | Waiver of Administrative Disqualification Hearing (Community Services Division) | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-712 | Behavioral Health Wraparound Support (BHWS) Request (Aging and Long-Term Support Administration (ALTSA) | ||
| 13-893 | Nurse Delegation: Request For Additional Units | ||
| 13-899 | Review of Medical Evidence | ||
| 13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | ||
| 13-906 | Therapy Evaluation for Bed Transfer / Positioning Devices (Typically Bed or Side Rails) (Home and Community Services) | ||
| 13-915 | Information for Respite Care Service Providers: Addendum to TCARE Assessment (Aging and Long-Term Support Administration) | ||
| 13-917 | Intensive Habilitation Services (IHS) Medical / Dental Services Authorization (Developmental Disabilities Administration) | ||
| 13-919 | Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration) | ||
| 13-920 | Outpatient Competency Restoration Program (OCRP) Discharge Summary |
