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
10-554 Environmental Tour - Bedrooms (Residential Care Services)
10-555 Resident Observations (Residential Care Services)
10-556 Resident Record Review (Residential Care Services)
10-557 Resident Medication Review (Residential Care Services)
10-558 Comprehensive Resident / Representative Interview (Residential Care Services)
10-558A Condensed Resident / Representative Interview (Residential Care Services)
10-559 Administrative Records Review (Residential Care Services)
10-559A Administrative Records Review Continuation (Residential Care Services)
10-559B Administrative Records Review - Former Staff and Others with Unsupervised Access (Residential Care Services)
10-560 Provider / Resident Manager Interview (Residential Care Services)
10-561 Staff Interview (Residential Care Services)
10-562 Exit Preparation Worksheet (Residential Care Services)
10-563 Residential Care Services Notes (Residential Care Services)
10-564 Adult Family Home Floor Plan Key (Residential Care Services)
10-570 Intake and Referral
10-571 Overnight Planned Respite Services Individualized Agreement
10-573 Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination
10-574A Transitional Care Planning Tracking: Part A. Transition Preparation (Developmental Disabilities Administration)
10-574B Transitional Care Planning Tracking: Part B. Active Coordinator of Transition (ACT) (Developmental Disabilities Administration)
10-574C Transitional Care Planning Tracking: Part C. Post Move and Stabilization (Developmental Disabilities Administration)
10-575 Adult Family Home (AFH) Inspection Packet (Residential Care Services)
10-577 Assisted Living Facility Other Contact Information - Attachment R
10-580 Adult Day Services Referral
10-583 DDA PASRR Cover Sheet
10-584 Data Summary Report and Recommendations (Developmental Disabilities Administration)