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 | |
|---|---|---|---|
| 15-314 | Client Necessary Supplemental Accommodation Representative Requirement Checklist | ||
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | ||
| 15-331 | Annual Assessment Checklist (Developmental Disability Administration) | ||
| 15-342 | Notice of Exception to Rule Decision | ||
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | ||
| 15-356 | DDA Community Protection Program Chaperone Agreement | ||
| 15-358 | Client Referral Summary (Developmental Disabilities Administration) | ||
| 15-360 | Residential Services Capacity Profile | ||
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | ||
| 15-376 | Skin Observation Protocols | ||
| 15-379 | Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)) | ||
| 15-380 | Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration) | ||
| 15-381 | Respite Assessment Worksheet | ||
| 15-382 | Positive Behavior Support Plan (PBSP) | ||
| 15-383 | Functional Behavioral Assessment (FA) | ||
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | ||
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | ||
| 15-388 | Alternative Living Certification Evaluation (Developmental Disabilities Administration) | ||
| 15-389 | Certified Community Residential Services and Support (CCRSS) Initial Application | ||
| 15-398 | Medically Intensive Children's Program (MICP) Application | ||
| 15-419 | Refusal of Services Statement | ||
| 15-424 | Staffed Residential Cost of Care Adjustment Request | ||
| 15-435 | Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration | ||
| 15-436 | Request for Adult Family Home Application Fee Waiver | ||
| 15-447 | Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services) |
