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 Form Name(desc) File Format
10-393 Cost Estimate Worksheet for Hearing Aids and Services
06-124 Cost of Care Adjustment (COCA) (Developmental Disabilities)
10-272 Cross-System Crisis Plan (DDA)
27-143 CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool
27-144 CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool
15-552 Curriculum Approval Application (Home and Community Services)
11-068 Customer Internship Program Internship Application (Division of Vocational Rehabilitation)
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)
13-738 DDA / DCYF Request to Cost Share (Developmental Disabilities Administration) (Department of Children, Youth, and Families)
15-568 DDA Alternative Living Provider Orientation (Developmental Disabilities Administration)
27-210 DDA Authorization for Release of Referral Video (Developmental Disabilities Administration)
15-356 DDA Community Protection Program Chaperone Agreement
14-549 DDA Companion Home Provider Application (Developmental Disabilities Administration)
15-318 DDA Crisis Diversion Bed Referral and Intake Information
16-237 DDA GovDelivery Communication Request (Developmental Disabilities Administration)
10-331 DDA Mortality Review Provider Report (Developmental Disabilities Administration)
13-911 DDA Nursing Service Referral (Developmental Disabilities Administration)
10-583 DDA PASRR Cover Sheet
10-623 DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review)
13-903 DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration)
10-688 DDA Specialty Adult Family Home (AFH) Pilot Monthly Client Goal and Progress Report (Developmental Disabilities Administration)
10-687 DDA Specialty Adult Family Home (AFH) Pilot: Strengths, Abilities, Interests, Learn (SAIL) (Developmental Disabilities Administration)
11-134 Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation)
27-219 Death Notification Checklist for Medical Providers (Developmental Disabilities Administration)
27-218 Death Notification Checklist for Residential Habilitation Center (RHC) Staff (Developmental Disabilities Administration)