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(desc) Form Name File Format
17-229 Pre-Admission Screening and Resident Review (PASRR) Records Request
17-230 Non-Emergency Medical Transportation (NEMT) for PASRR Program Request
17-231 Mental Incapacity Evaluation (MIE) Contractor Travel Plan
17-238 ODHH Approved Sign Language Interpreter Complaints
17-253 DSHS Background Check System (BCS) Access Request
17-257 Companion Home Client Budget Worksheet (Developmental Disabilities Administration)
17-258 Companion Home Client Cash Ledger (Developmental Disabilities Administration)
17-259 Companion Home Client Inventory Record
17-260 Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration)
17-261 Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing)
17-262 Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration)
17-263 Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation)
17-264 DVR Background Check Reporting (Division of Vocational Rehabilitation)
17-265 DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation)
17-266 Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation)
17-284 Preferred Sign Language Interpreter List (Office of Deaf and Hard of Hearing)
17-292 Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing)
17-294 Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration)
17-295 Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration)
17-296 Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration)
17-297 Removal and Transport Directive (Behavioral Health Administration)
17-299 Vendor Agreement Information (Behavioral Health Administration)
17-300 BHA Personal Information Release (Behavioral Health Administration)
17-301 Medical Expense Examples (Community Services Division, Economic Services Administration)
17-305 DPI Authorization for Release of Information (Division of Program Integrity)