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
02-516 Adult Family Home Resident Personal Belongings Inventory (Residential Care Services)
03-076 Employee Personal Property Damage/Loss Claim
06-188 Adult Protective Services (APS) Investigations Fact Sheet (Aging and Long-Term Support Administration)
07-098 Self Employment Monthly Sales and Expense Worksheet
10-370 Assisted Living Facility Notes / Worksheet - Attachment L
10-371 Assisted Living Facility Exit Preparation Worksheet - Attachment M
10-393 Cost Estimate Worksheet for Hearing Aids and Services
10-442 Goal Setting and Action Planning Worksheet
10-487 Assisted Living Facility Medication Pass Worksheet - Attachment Q
10-583 DDA PASRR Cover Sheet
10-611 Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (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)
10-664 New or Update Provider Information Worksheet (Developmental Disabilities Administration)
10-696 Assisted Living Facility Medication Observation Worksheet (Residential Care Services)
11-067 Monthly Budget Worksheet (Division of Vocational Rehabilitation)
11-071 DVR Employer Expense Worksheet (Division of Vocational Rehabilitation)
11-088 DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet
11-098 Vocational Assessment Worksheet
11-118 Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation)
11-119 Informational Interview Worksheet (Division of Vocational Rehabilitation)
11-133 Jobs and Training Inventory (Division of Vocational Rehabilitation)
11-149 Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet
11-154 Personal Pathway