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 | |
|---|---|---|---|
| 06-125 | Residential Allowance Request / Insufficient Income (Developmental Disabilities Administration) | ||
| 13-939 | Residential Care Services (Adult Family Home, Assisted Living Facility, Enhanced Services Facility) Community Programs Infection Prevention and Control (ICP) InspectionTool | ||
| 10-645 | Residential Certification Evaluation Client Interview (Developmental Disabilities Administration) | ||
| 10-646 | Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration) | ||
| 10-647 | Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration) | ||
| 15-494 | Residential Habilitation Center (RHC) / Individual Habilitation Plan (IHP) / Individual Plan of Care (IPOC) Meeting Notification (Developmental Disabilities Administration) | ||
| 02-632 | Residential Provider's Report of Weapon Ownership in Residential Setting | ||
| 17-296 | Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration) | ||
| 17-295 | Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration) | ||
| 10-666 | Residential Quality Assurance Certification Evaluation Checklist for Overnight Planned Respite Services Providers (Developmental Disabilities Administration) | ||
| 15-564 | Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration) | ||
| 05-274 | Residential Referral Transition (Developmental Disabilities Administration) | ||
| 15-360 | Residential Services Capacity Profile | ||
| 10-403 | Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult | ||
| 10-328 | Residential Site Approval Request | ||
| 11-130 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Eligibility Determination (Home and Community Services) | ||
| 15-596 | Residential Support Waiver (RSW) Expanded Behavior Supports (EBS) Referral (Home and Community Services) | ||
| 06-177 | Residential Training Roster / Reimbursement (Developmental Disabilities Administration) | ||
| 10-635 | Residential Transition Exchange of Information (Developmental Disabilities Administration) | ||
| 15-381 | Respite Assessment Worksheet | ||
| 13-899 | Review of Medical Evidence | ||
| 05-259 | Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment) | ||
| 10-389 | Room List For Assisted Living Facilities (ALF) | ||
| 15-560 | Room Requirements Checklist (Home and Community Services) | ||
| 05-010 | Rule Exception Request |
