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 | |
|---|---|---|---|
| 11-163 | Applicant Certification and Assurances (Division of Vocational Rehabilitation) | ||
| 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) | ||
| 11-167 | Internship: Employer Evaluation | ||
| 11-168 | Internship: Customer Evaluation | ||
| 11-180 | Discovery Profile Report (Developmental Disabilities Administration) | ||
| 12-008 | Basic Food Affidavit Replacement for Household Disaster | ||
| 12-195 | Disqualification Consent Agreement | ||
| 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) | ||
| 13-021 | Physical Evaluation | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 13-645 | Adult Family Home Injuries and Accidents Log | ||
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | ||
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | ||
| 13-678A | Nurse Delegation: PRN Medication | ||
| 13-678B | Nurse Delegation: Assumption of Delegation | ||
| 13-680 | Nurse Delegation: Rescinding Delegation | ||
| 13-681 | Nurse Delegation: Change in Medical Orders | ||
| 13-692A | Assisted Living Facility (ALF) Dementia Screening Tool | ||
| 13-712 | Behavioral Health Wraparound Support (BHWS) Request (Aging and Long-Term Support Administration (ALTSA) | ||
| 13-713 | Fast Track Service Agreement |
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