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 | |
|---|---|---|---|
| 10-602 | Enhanced Services Facility Information Changes | ||
| 10-603 | Nursing Home Information Changes | ||
| 10-604 | Supported Living Information Changes (Residential Care Services) | ||
| 10-605 | ICF / IID Information Changes (Residential Care Services) | ||
| 10-611 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services) | ||
| 10-613 | Community Residential Services and Supports (CCRSS) Certification Evaluation Client Supports Observation (Residential Care Services) | ||
| 10-614 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services) | ||
| 10-615 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Representative Interview (Residential Care Services) | ||
| 10-616 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services) | ||
| 10-617 | Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services) | ||
| 10-617A | Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) General Environment and Safety Worksheet (Residential Care Services) | ||
| 10-617B | Certified Community Residential Services and Supports (CCRSS) Group Training Home (GTH) Client Environment and Safety Worksheet (Residential Care Services) | ||
| 10-618 | Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services) | ||
| 10-619 | Certified Community Residential Services and Supports (CCRSS) Staff Background Check and Record Review (Residential Care Services) | ||
| 10-620 | Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services) | ||
| 10-621 | Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services) | ||
| 10-622 | Certified Community Residential Services(CCRSS) Group Training Home Food Service Review (Residential Care Services) and Supports | ||
| 10-623 | DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review) | ||
| 10-625 | State Task Checklist (Aging and Long-Term Support Administration) | ||
| 10-626 | Staffing Pattern (Aging and Long-Term Support Administration) | ||
| 10-627 | Liability Insurance Review (Aging and Long-Term Support Administration) | ||
| 10-628 | Trust Fund Review (Aging and Long-Term Support Administration) | ||
| 10-629 | Pet Record Review (Aging and Long-Term Support Administration) | ||
| 10-630 | Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration) | ||
| 10-631 | Staff Qualification and Background Review (Aging and Long-Term Support Administration) |
