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 | Form Name(desc) | File Format | |
|---|---|---|---|
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
| 02-566 | Protected Health Information (PHI) Amendment | ||
| 14-349 | Protective Payee Assessment |
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| 14-453 | Protective Payee Decision | ||
| 14-426 | Protective Payee Payment Plan, Case Assignment, and Closure Notice |
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| 01-110A | Protective Payee Periodic Social Services Report | ||
| 01-110 | Protective Payee Report | ||
| 01-110C | Protective Payee Report Continuation | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 27-123 | Provider Owned Housing Memorandum of Understanding Renter Attestation |
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| 27-124 | Provider Owned Housing Memorandum of Understanding Residential Provider Attestation | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 10-232 | Provider Referral Letter For Residential Services (Developmental Disabilities Administration) | ||
| 13-851 | Psychiatric Referral Summary | ||
| 13-865 | Psychological / Psychiatric Evaluation | ||
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | ||
| 10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | ||
| 13-585A | Range of Joint Motion Evaluation Chart | ||
| 02-716 | Rapid Response Team 2 Request (Residential Care Services) (Aging and Long-Term Support Administration) | ||
| 13-944 | RCS (AFH, ALF, and ESF) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) (Adult Family Home, Assisted Living Facility, and Enhanced Services Facility) | ||
| 13-940 | RCS (AFH, ALF, ESF) Community Programs Infection Prevention and Control (IPC) Complaint Investigation Pathway (Residential Care Services) | ||
| 13-941 | RCS (AFH, ALF, ESF) Infection Prevention and Control (IPC) Complaint Investigation Tool (Residential Care Services) | ||
| 13-945 | RCS Certified Community Residential Services and Supports (CCRSS) Infection Prevention and Control (IPC) Assessment Notes (Residential Care Services) | ||
| 15-456 | RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults | ||
| 10-501 | Referral to DSHS for Basic Food Employment and Training (BFET) |
