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.
If you do not have Microsoft Word, download Microsoft Viewer. This allows you to open, view, and print Word forms. If asked for a password when using Microsoft Word forms, select the cancel button to continue. Passwords prevent changes being made to the form's content.
Additionally, you may download the free Shana Informed filler to electronically complete Shana forms below. On opening your first Shana form, you will be asked to enter a registration key. Please enter 32064015014070671 (you only need to enter this once).
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.
Search tip: You may hold down the Ctrl key and type the F key to help find a specific form by number or key word. This will call up the "Find" dialogue box. Enter the number or title word(s) and select "Find Next."
| Number | Title | Format |
|---|---|---|
| 00-379 | Service Delivery Outcome Report Non-Supported Employment (Division of Vocational Rehabilitation) | Word, PDF |
| 00-380 | Service Delivery Outcome Report Supported Employment (Division of Vocational Rehabilitation) | Word, PDF |
| 00-381 | Service Delivery Outcome Plan (Division of Vocational Rehabilitation) | Word, PDF |
| 00-381A | Service Delivery Outcome Plan Addendum (Division of Vocational Rehabilitation) | Word, PDF |
| 01-110 | Protective Payee Report | Word, PDF |
| 01-110A | Protective Payee Periodic Social Services Report | Word, PDF |
| 01-110C | Protective Payee Report Continuation | Word, PDF |
| 01-210 | Transmittal of Client Funds from theProtective Payee | Word, Shana, PDF |
| 02-327 | JRA Work Request (Juvenile Justice and Rehabilitation Administration) | Word, PDF |
| 02-516 | Adult Family Home Resident Personal Belongings Inventory | Word, PDF |
| 02-528 | Fair Hearing Withdrawal | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Serbo-Croatian, Somali, Spanish, Vietnamese |
| 02-556 | Request for Exception to Policy (ETP) for Use of Restrictive Procedures (DDA) | Word, PDF |
| 02-573 | Background check Identification Verification (Office of Deaf and Hard of Hearing) | Word, PDF |
| 02-574 | Application for Advisory Body Appointment | Word, PDF |
| 02-578 | TED Monthly Client Contact Report (Office of Deaf and Hard of Hearing) | Word, PDF |
| 02-586 | Temporary Employment Hours Tracking Log | Word, PDF | 02-587 | CLIP/CSO Communication | Word, PDF |
| 02-589 | Companion Home Outside Employment Notification (Division of Developmental Disabilities) | Word, PDF |
| 02-592 | Application for Approval of Interpreter Continuing Education Activity | Word, PDF |
| 03-076 | Employee Personal Property Damage/Loss Claim | Word, PDF |
| 03-077 | Release of All Claims | Word, PDF |
| 03-133 | Employee/Volunteer Personal Incident Report | Word, PDF |
| 03-387 | Notice of Privacy Practices for Client Confidential Information | English:
Word,
PDF
Other languages (PDF): Albanian, Amharic, Arabic, Bengali, Bulgarian, Burmese, Cambodian, Chinese, Haitian-Creole/French-Creole, Estonian, Farsi, French, German, Hindi, Hmong, Hungarian, Ilocano, Indonesian, Italian, Japanese, Karen, Korean, Kurdish, Laotian, Marshallese, Mien, Oromo, Polish, Nepali, Portuguese, Punjabi, Romanian, Russian, Samoan, Somali, Serbo-Croatian, Spanish Word, Spanish, Swahili, Tagalog, Tamil, Thai, Tibetan, Tigrigna, Tongan, Trukese, Turkish, Ukrainian, Urdu, Vietnamese |
| 03-387A | Notice of Privacy Practices for Client Confidential Information without Acknowledgement | |
| 03-389 | Witness Statement | Word, PDF |
| 03-389A | Assault Benefits Program Witness Statement | Word, PDF |
| 03-391 | Employee Report of Resident/Client Assault (RCW 72.01.045, RCW 74.04.790) | Word, PDF |
| 03-394 | Supervisor's Review of Employee Report of Resident/Client Assault | Word, PDF |
| 03-430 | Alternative Work Schedule Request and Review | Word, PDF |
| 03-478 | Children's Administration Travel Authorization | Word, PDF |
| 04-220 | Family Ancestry Chart (Children's Administration) | English:
Word,
PDF Other languages (PDF): Laotian, Spanish (Word), Spanish Tagalog |
| 04-220A | Indian Heritage Questionnaire | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 04-416 | DBHR Target Data Elements Assessment/Admission Setup | Word, PDF |
| 04-416A | DBHR Target Data Elements Discharge or ADATSA Closure | Word, PDF |
| 04-417 | DBHR Target Detox Short Form | Word, PDF |
| 04-418 | DBHR Target Treatment Activities | Word, PDF |
| 04-419 | DBHR Target Client Support Activities (Non-Treatment) | Word, PDF |
| 04-420 | DBHR Target Agency Staff | Word |
| 04-423 | DBHR Target Change of Circumstances | Word, PDF |
| 04-432 | Treatment Plan and Change Report (DASA) | Word, PDF |
| 04-433 | ADATSA/Adult Assessment | Word, PDF |
| 04-433A | Adult/ADATSA Assessment (Page 9): Treatment Recommendations | Word, PDF |
| 04-433B | ADATSA/Adult Assessment ADATSA Treatment Eligibility | Word, PDF |
| 04-436 | DBHR Target Group Treatment Activities | Word, PDF |
| 04-437 | DBHR Target Agency Support Activities (Non-Treatment) | Word, PDF |
| 04-438 | DBHR Target Group Support Activities | Word, PDF |
| 04-442 | Nursing Home Credit Balance Report PDF Instructions |
Excel, PDF |
| 04-443 | Character, Competence, and Suitability Evaluation for Unsupervised Access to Adults | Word, PDF |
| 04-444 | DBHR Target Data Elements Waiting List - First Contact | Word, PDF |
| 05-010 | Rule Exception Request | Word, PDF |
| 05-013 | Request for Hearing | English:
Word,
PDF Other languages (PDF): Arabic, Bosnian, Cambodian, Chinese, Ilocano, Japanese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 05-180 | Federal Grant Application (Washington State Partnership Council on Juvenile Justice) | Shana, Word, PDF |
| 05-180B | State Grant Application (Washington State Partnership Council on Juvenile Justice) | Shana, Word, PDF |
| 05-180C | Juvenile Detention Alternatives Initiative Grant Application (Washington State Partnership Council on Juvenile Justice) | Shana, Word, PDF |
| 05-180E | State Gang Prevention and Intervention Application (Washington State Partnership Council on Juvenile Justice) | Shana, Word, PDF |
| 05-180F | Federal Grant Application - B (Washington State Partnership Council on Juvenile Justice) | Shana, Word, PDF |
| 05-210 | Exceptional Cost Request (ECR) (Children's Administration) | Word, PDF |
| 05-210A | Attachment A Exceptional Cost Foster Care (Children's Administration) | Word, PDF |
| 05-218 | LIST Examination Application | Word, PDF |
| 05-234 | Unit of Local Government (ULG) Application (JRA) | Word, PDF |
| 05-234A | Unit of Local Government (ULG) Application Continuation (JRA) | Word, PDF |
| 05-246 | Notice of Action Exception to Rule (Home and Community Services) | English:
Word,
PDF Other languages (PDF) Cambodian, Chinese, Farsi, Hungarian, Japanese, Korean, Kurdish, Laotian, Polish, Punjabi, Russian, Somali, Spanish, Tagalog, Ukrainian, Urdu, Vietnamese |
| 06-123 | Nursing Assistant Training and Testing Reimbursement | Word, PDF |
| 06-124 | Cost of Care Adjustment Request (Division of Developmental Disabilities | Excel |
| 06-125 | Residential Allowance Request | Excel |
| 06-159 | Psychologist and Sex Offender Treatment Provider Invoice (DDA) | Word, PDF |
| 06-160 | Adoption Support Monthly Counseling Billing | Word, PDF |
| 06-162 | Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral | Word, PDF |
| 07-042B | Self-Employment Income Report | English:
Word,
PDF
Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Hmong, Korean, Laotian, Mongolian, Portuguese, Punjabi, Romanian, Russian, Somali, Spanish, Ukrainian, Vietnamese |
| 07-066 | CCSP Award/Change Letter | English:
Word,
PDF
Other languages (PDF): Karen, Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Somali, Spanish, Trukese, Vietnamese |
| 07-075 | In-Home/Relative Provider |
English:
Word.
PDF Other languages (PDF): Russian, Somali, Spanish |
| 07-076 | Request for Information (Child Care Subsidy Programs) | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Armenian, Burmese, Cambodian, Chinese, Dzongkha, Haitian-Creole, Farsi, French, Japanese, Karen, Kirundi, Korean, Kurdish, Laotian, Mandinka, Marshallese, Nepali, Oromo, Portuguese, Punjabi, Russian, Samoan, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Turkish, Trukese, Ukrainian, Urdu, Vietnamese |
| 07-081 | Participation Reimbursement | Excel, PDF |
| 07-086 | Notice of Discharge (Division of Developmental Disabilities) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese |
| 07-087 | Eligibility Checklist for DDA State Supplementary Payments (SSP) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 07-090 | Caregiver Monthly Mileage | English:
Word,
PDF |
| 07-097 | Individual Provider Planned Action Notice Training / Certification (Home and Community Services) |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 07-098 | Self Employment Monthly Sales and Expense Worksheet (Economic Services Administration) |
Word,
Excel,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 07-101 | School-Aged Children Change of Circumstances (Economic Services Administration) |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 09-004C | Voluntary Placement Agreement for Child or Youth with Developmental Disabilities | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 09-013 | Vendor Affidavit of Lost, Stolen, or Destroyed Warrant | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Spanish, Spanish Word, Vietnamese |
| 09-052 | Affidavit of Forged Endorsement | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 09-097 | Record of Official Actions (Juvenile Rehabilitation Administration) | Word, PDF |
| 09-341 | Order of Parole Conditions (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Samoan, Somali, Spanish, Vietnamese |
| 09-508 | Waiver of Statute of Limitations Defense | English:
Word,
PDF Other languages (PDF): Spanish, Tigrigna, Vietnamese |
| 09-520 | Request for Conference Board | English:
Word,
PDF Other languages (PDF): Marshallese, Russian, Somali, Spanish, Tigrigna, Trukese, Vietnamese |
| 09-536 | Inquiry to Bureau of Indian Affairs (BIA) | Word, PDF |
| 09-537 | Notice to Non-Federally Recognized or Canadian Indian Tribe or Band RE: Court Hearing | Shana, PDF |
| 09-539 | Inquiry to Indian Tribe, Band, or Nation | Word, PDF |
| 09-539A | Inquiry to Indian Tribe, Band, or Nation, and Notice of Incarceration of a Youth | Word, PDF |
| 09-653 | Background Authorization | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Chinese, Dinka, French, Farsi, Karen, Kayah, Kirundi Korean, Laotian, Marshallese, Nepali, Nuer, Oromo, Polish, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Swahili, Tagalog, Tigrigna, Trukese, Ukrainian, Vietnamese |
| 09-670 | Discharge Report (Juvenile Rehabilitation Administration) | Word, PDF |
| 09-705 | Order of Continued Detention or Release (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 09-706 | Parole Revocation Petition (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Samoan, Somali, Spanish, Vietnamese |
| 09-713 | Order Denying Parole Revocation Petition (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 09-714 | Order Revoking Parole (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 09-746 | Notice of Sex/Kidnapping Offender Registration Requirements | Word, PDF |
| 09-746A | DSHS Sex/Kidnapping Offender Preregistration | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 09-747 | Notification of Release (Juvenile Rehabilitation Administration) | Word, PDF |
| 09-747A | Notification of Sex Offender Release (Juvenile Rehabilitation Administration) | Word, PDF |
| 09-760 | Motion, Declaration of Child's Return from Voluntary Foster Care Placement, and Order of Dismissal | Shana, PDF |
| 09-761 | Indian Identity Request | English:
Word,
PDF Other languages (PDF): Chinese, Croatian, French, Hmong, Indonesian, Japanese, Marshallese, Russian, Somali, Spanish Word, Spanish, Tagalog, Thai, Tigrigna, Tongan, Vietnamese |
| 09-762A | Petition for Court Validation of Voluntary Consent to Foster Care Placement of An Indian Child (Indian Child with Disabilities) (Division of Developmental Disabilities) | Word, PDF |
| 09-765 | Declaration of Adoption Facilitator - Indian Child | Word, PDF |
| 09-777 | Indian Child: Compliance Checklist | Shana, PDF |
| 09-808 | JRA Notice and Finding of financial Responsibility | English:
Shana,
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese |
| 09-809 | WorkFirst Work Experience (WEX) Referral | Word, PDF |
| 09-810 | WorkFirst Work Experience (WEX) Agreement | Word, PDF |
| 09-837 | Disclosure of Confidential HIV/AIDS Information | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 09-860 | Interpreter Services Core Provider Agreement | Word, PDF |
| 09-876 | Permanency Planning Findings and Order (Child With a Developmental Disability) | Word, PDF |
| 09-877 | Notice of Hearing Re: Out-of-Home Placement (Child with a Developmental Disability) | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 09-878 | Order Approving Continued Out-of-Home Care (Child With a Developmental Disability) | Word, PDF |
| 09-892 | Petition for Review of Continued Out-of-Home Care (Child with Disabilities) (Division of Developmental Disabilities | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 09-893 | Periodic Review of Individual Service Plan (DDA) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Samoan, Somali, Spanish Word, Spanish, Vietnamese |
| 09-894 | Contract Renewal of Acknowledgement of Requirements to Report Criminal Convictions (Juvenile Justice and Rehabilitation Administration) | Word, PDF |
| 09-895 | JRA Contractor Requirements for Responding to Situations of Sexual Misconduct (Juvenile Justice and Rehabilitation Administration) | Word, PDF |
| 09-961 | Nursing Assistant Training Program (NATCEP) Declaration of the Program Director | Word, PDF |
| 09-966 | Authorization to Release Information to the Court (Children's Administration) | Word, PDF |
| 09-979 | Marital History | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 09-995 | Companion Home Contract Evaluation (DDA) | Word, PDF |
| 09-997 | Adoption Support Worksheet | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Spanish Word, Spanish, Vietnamese |
| 09-998 | Application For The Adoption Support Program and/or Reimbursement of Adoption Finalization Costs | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Russian, Spanish Shana, Spanish, Vietnamese |
| 09-999 | Exhibit B Rate Sheet Licensed Staffed Residential Contract | Excel, PDF |
| 10-016 | Certification for License of Foster Home | Word, PDF |
| 10-017 | Termination of Foster Home License | Word, PDF |
| 10-043 | Family Home Study | English:
Word,
PDF Other languages (PDF): Spanish |
| 10-061 | Child's Registration | Word, PDF |
| 10-083 | EPSDT Assessment | Word, PDF |
| 10-104B | Service Verification/Attendance Record For Alternative Living Providers (DDA) | Word, PDF |
| 10-114 | Adoption Data Card | Word, PDF |
| 10-161 | Mental Health Evaluation and Treatment Application for Certification | Shana, Word, PDF |
| 10-165 | Application for License (Community Mental Health Services) | Word, PDF |
| 10-182 | Home Study File Checklist for Foster Care and/or Adoption | Word, PDF |
| 10-183 | Foster Home Inspection Checklist | English:
Word,
PDF Other languages (PDF): Arabic, Spanish Word, Spanish |
| 10-209 | Application for Program Certification (Children's Administration) | Word, PDF |
| 10-210 | Staff Statement of Qualifications (Children's Administration) | Word, PDF |
| 10-214 | Preauthorization for Services (Children's Administration) |
Word,
PDF Other languages (PDF): Korean |
| 10-217 | Nurse Delegation: Nursing Assistant Credentials and Training | Word, PDF |
| 10-231 | Adult Family Home (AFH) Placement Checklist (DDA) | Word, PDF |
| 10-232 | Provider Referral Letter For Supported Living/Group Home Providers | Word, PDF |
| 10-232A | Provider Referral Letter | Word, PDF |
| 10-234 | Individual with Challenging Support Issues (DDA) | Word, PDF |
| 10-237 | Notice of Transfer or Discharge (Residential Care) | English:
Word,
Shana,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish Shana, Spanish, Vietnamese |
| 10-238 | Request for an Administrative Hearing (Residential Care Services) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Shana, Spanish, Vietnamese |
| 10-241 | Report to Protective Services (Juvenile Rehabilitation Administration) | Word, PDF |
| 10-244 | Shared Parenting Plan (DDA) | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 10-246 | Permanency Plan (Division of Developmental Disabilities | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 10-248 | Compliance Agreement | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 10-248A | Compliance Agreement Continuation | Word, PDF |
| 10-255 | Public Health Nurse (PHN) Summary and Recommendations | Word, PDF |
| 10-257 | Voluntary Placement Services Foster Care Medical Team (FCMT) Communication (DDA) | Word, PDF |
| 10-258 | Individual with Community Protection Issues (DDA) | Word, PDF |
| 10-261 | Foster Care Rate Assessment | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese |
| 10-268 | Pre-Placement Agreement (Division of Developmental Disabilities | Word, PDF |
| 10-269 | Alternative Living Services Plan and Provider Report (DDA) | Word, PDF |
| 10-270 | Adult Family Home/Boarding Home Admission Agreement(s) Attestation | Word, PDF |
| 10-272 | Cross-Systems Crisis Plan (DDA) |
Word, PDF |
| 10-276 | WTRS Consumer Response (Office of Deaf and Hard of Hearing) | Word, PDF |
| 10-277 | Request for Children's Residential Services | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 10-287 | Consumer Request for Special Needs Child Care Rate (Division of Child Care and Early Learning) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 10-288 | Provider Request for Additional Special Needs Payment (Division of Child Care and Early Learning) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 10-290 | Policy Agreement (Children's Administration) | English:
Word,
PDF Other languages (PDF): Arabic, Korean, Spanish Word, Spanish |
| 10-294 | Mandatory Report to Law Enforcement | Word, PDF |
| 10-301 | Notification of Eligibility Review (Division of Developmental Disabilities) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Tagalog, Vietnamese |
| 10-326 | Staffed Residential Rate Proposal | Excel, PDF |
| 10-327 | Residential Staff Schedule Reporting | Excel |
| 10-328 | Residential Site Approval Request (DDA) | Word, PDF |
| 10-329 | Informed Consent for ICAP (Division of Developmental Disabilities) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 10-330 | Request For Legal Advice | Word, PDF |
| 10-331 | DDA Mortality Review Part 1. Provider Report | Word, PDF |
| 10-334 | Monitoring of Side Effects Scale (MOSES) (DDA) | Word, PDF |
| 10-335 | Dyskinesia Identification System: DISCUS Rating (DDA) | Word, PDF |
| 10-337 | Important Information for SSP Recipients and Their Payees (DDA) | English:
Word,
PDF Other languages (PDF): Arabic, Bosnian, Cambodian, Chinese, Japanese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 10-338a | Nursing Care Consultant (NCC) Home Visit Update (DDA) | Word, PDF |
| 10-339 | Nursing Care Consultant (NCC) Assessment (DDA) | Word, PDF |
| 10-348 | Information Checklist (DDA) | Word, PDF |
| 10-349 | Comprehensive Review Tool | Word, PDF |
| 10-351 | Disclosure of Services (ADSA Boarding Homes) | Word, PDF |
| 10-353 | Documentation Request for Medical or Disability Condition | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Swahili, Vietnamese |
| 10-354 | Application for Family Home Care for Children in Out of Home Placements | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 10-356 | Application for Peer Counselor | Word, PDF |
| 10-359 | Boarding Home Pre Inspection Preparation - Attachment A | Word, PDF |
| 10-360 | Boarding Home Request for Documentation - Attachment B | Word, PDF |
| 10-361 | Boarding Home Resident List - Attachment C | Word, PDF |
| 10-362 | Boarding Home Resident Characteristic Roster - Attachment D | Word, PDF |
| 10-363 | Boarding Home Resident Group Meeting - Attachment E | Word, PDF |
| 10-364 | Boarding Home Resident Sample Selection - Attachment F | Word, PDF |
| 10-365 | Boarding Home Resident Group Interview - Attachment G | Word, PDF |
| 10-366 | Boarding Home Collateral Interview - Attachment H | Word, PDF |
| 10-367 | Boarding Home Environmental and Food Service Observations - Attachment I | Word, PDF |
| 10-368 | Boarding Home Resident Record Review - Attachment J | Word, PDF |
| 10-369 | Boarding Home Staff Record - Attachment K | Word, PDF |
| 10-370 | Boarding Home Resident Care Service Notes - Attachment L | Word, PDF |
| 10-371 | Boarding Home Exit Preparation Worksheet - Attachment M | Word, PDF |
| 10-372 | Boarding Home Contract Requirements - Attachment N | Word, PDF |
| 10-373 | Boarding Home Environmental Observations - Contract Requirements - Attachment O | Word, PDF |
| 10-376 | Password Change/Confirmation Request Nursing Home Facility Log-in | |
| 10-377 | Notification of Age Four (4) Eligibility Expiration- | English: Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, German, Japanese, Karen, Korean, Laotian, Polish, Portuguese, Russian, Samoan, Somali, Spanish Word, Spanish, Vietnamese |
| 10-378 | Notification of Age Ten (10) Eligibility Expiration | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 10-382 | Naturalization Services Pre-Screening | Word, PDF |
| 10-388 | Referral For Initial Foster Home License | Word, PDF |
| 10-389 | Approved Sleeping Room List For Boarding Homes | Word, PDF |
| 10-389A | Additional Rooms List For Boarding Homes | Word, PDF |
| 10-393 | Cost Estimate Worksheet for Hearing Aids and Services | Word, PDF |
| 10-395 | Intensive Family Preservation Service (IFPS)/Family Preservation Service (FPS) Exit Summary | Word, PDF |
| 10-396 | SSI Letter (DDA) | Word, PDF |
| 10-400 | Information Request Letter | English:
Word,
PDF Other languages (PDF): Armenian, Cambodian, Chinese, Farsi, French, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 10-402 | Child Placing Agency Referral | Word, Excel, PDF |
| 10-403 | Abuse/Neglect Reporting Requirement Information | Word, PDF |
| 10-405 | Foster Home Re-Assessment | Word, PDF |
| 10-406 | Employed Foster Parent Child Care Plan | English:
Word,
PDF Other languages (PDF): Korean, Spanish |
| 10-410 | Adult Family Home License Application | Word, PDF |
| 10-411 | Consumer Response: Do Not Hang Up Complaint | Word, PDF |
| 10-412 | Adult Family Home License Relinquishment Letter | Word, PDF |
| 10-413 | Application For Contract For Currently Licensed Boarding Home | Word, PDF |
| 10-416 | Foster Home Monitoring Visit | Word, PDF |
| 10-417 | Adult Family Home Caregiver Experience Attestation (CEA) Form A for Applicants for Licensure | Word, PDF |
| 10-418 | Fostering Well-Being Care Coordinator Referral | Word, PDF |
| 10-419 | Licensing and Safety Supervision Plan For Site Specific Conditions |
Word,
PDF Other languages (PDF): Arabic, Spanish, Spanish Word |
| 10-422 | AFH Quality Improvement Initial Visit | Word, PDF |
| 10-423 | Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services | Word, PDF |
| 10-424 | Voluntary Participation Statement (Developmental Disability Administration) |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 10-425 | Respite Provider Reference Questionnaire | English:
Word,
PDF Other languages (PDF): Spanish |
| 10-426 | Respite Care Applicant Letter | English:
Word,
PDF Other languages (PDF): Spanish |
| 10-427 | School District Communication | Word, PDF |
| 10-428 | Caregiver Support Plan (Children's Administration) |
Word,
PDF Other languages (PDF): Spanish |
| 10-432 | Extended Foster Care Program (Children's Administration) | Word, PDF |
| 10-435 | Home Study Application Received Notice (Children's Administration) |
Word,
PDF Other languages (PDF): Korean, Spanish Word, Spanish |
| 10-436 | Foster Care License Renewal Notice (Children's Administration) |
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 10-437 | Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility | Word, PDF |
| 10-438 | Long-Term Care Partnership (LTCP) Asset Designation | Word, PDF |
| 10-441 | Individuals: Subscription and Directory (Office of the Deaf and Hard of Hearing) | Word, PDF |
| 10-441LP | Individuals: Subscription and Directory - Large Print (Office of the Deaf and Hard of Hearing) | Word, PDF |
| 10-442 | Goal Setting and Action Plan Worksheet (Home and Community Services) | Word, PDF |
| 10-443 | Organizations: Subscription and Directory (Office of the Deaf and Hard of Hearing) | Word, PDF |
| 10-444 | Relative Caregiver / Suitable Other Placement Fact Sheet and Home Study Checklist (Children's Administration) |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 10-448 | Nurse Delegation Contract Monitoring Chart Audit | Word, PDF |
| 10-450 | Statement of Qualifications and Verification of Issues Discussed (Children's Administration) | Word, PDF |
| 10-453 | Household Safety Inspection for Unlicensed Relatives / Suitable Others (Children's Administration) | Word, PDF |
| 10-454 | Children's Administration Caregiver Authorization | Word, PDF |
| 10-455 | Medical Log (Children's Administration) | Word, PDF |
| 10-457 | Medical and Treatment Letter for Relative Placement (Children's Administration) | Word, PDF |
| 10-458 | Home Study Referral Notice (Children's Administration) |
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 10-459 | Courtesy Supervision Referral Checklist (Children's Administration) | Word, PDF |
| 10-460 | Treehouse Educational Advocacy Referral (Children's Administration) | Word, PDF |
| 10-462 | User Application and Agreement (Children's Administration) | Word, PDF |
| 10-463 | FamLink Data Access Request / Change (Children's Administration) | Word, PDF |
| 10-464 | FamLink Access Application and Agreement (Children's Administration) | Word, PDF |
| 10-466 | Early Family Support Services Referral (Children's Administration) | Word, PDF |
| 10-467 | ADSA Sentence / Copy Design Folstein MMSE (Home and Community Services) | Word, PDF |
| 10-469 | Notice to Clients Who Employ An Individual Provider (Home and Community Services) |
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 10-470 | Children's Intensive In-Home Behavioral Support (CIIBS) Service Request (Developmental Disabilities Administration) | Word, PDF |
| 10-471 | Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration) | Word, PDF |
| 10-472 | Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration) | Word, PDF |
| 10-475 | Early Intervention Program (EIP) Exit Summary (Children's Administration) | Word, PDF |
| 10-476 | Early Family Support Services (EIP) 90 Day Review (Children's Administration) | Word, PDF |
| 10-478 | Early Family Support Services (EIP) Exit Summary (Children's Administration) | Word, PDF |
| 10-479 | Early Intervention Program (EIP) 90 Day Review (Children's Administration) | Word, PDF |
| 10-480 | Comprehensive Family Assessment (Children's Administration) | Word, PDF |
| 11-019 | Vocational Information (Division of Vocational Rehabilitation) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 11-022 | Application for Vocational Rehabilitation Services | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Ukrainian, Vietnamese |
| 11-045 | Work Experience (WEX) Referral (Food Stamp Employment and Training) | Word, PDF |
| 11-046 | Work Experience (WEX) Agreement (Food Stamp Employment and Training) | Word, PDF |
| 11-055 | Acknowledgement of My Responsibilities as the Employer of Individual Providers (DDA) | English:
Word,
PDF Other languages (PDF): Arabic, Bosnian, Burmese, Cambodian, Chinese, Farsi, Hmong, Karen, Korean, Laotian, Nepali, Punjabi, Russian, Samoan, Serbo Croatian, Somali, Spanish Word, Spanish, Ukrainian, Vietnamese |
11-058 | Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation) | Word, PDF |
| 11-066 | Assistive Listening Device(s) (ALD) Sign-Out Register (Office of Deaf and Hard of Hearing) | Word, PDF |
| 11-067 | Monthly Budget Worksheet (Division of Vocational Rehabilitation | Excel, PDF |
| 11-068 | DVR Internship Application (Division of Vocational Rehabilitation) | Word, PDF |
| 11-069 | DVR Internship Agreement (Division of Vocational Rehabilitation) | Word, PDF |
| 11-070 | DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation) | Word, PDF |
| 11-071 | DVR Employer Expense Worksheet (Division of Vocational Rehabilitation) | Word, PDF |
| 11-072 | DVR Internship Evaluation (Division of Vocational Rehabilitation) | Word, PDF |
| 11-078 | Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation) | Word, PDF |
| 11-079 | Centers for Independent Living (CILs), Title VII, Part B Annual Report (Division of Vocational Rehabilitation) | Word, PDF |
| 11-080 | Centers for Independent Living (CILs), Title VII, Part B Monthly Report (Division of Vocational Rehabilitation) | Word, PDF |
| 11-084 | Employees Approved to Provide IL Services and Type of Service Provided (Division of Vocational Rehabilitation) | Word, PDF |
| 11-090 | Centers for Independent Living (CILs) Title VI, Part B Annual Expenditure Report | Excel, PDF |
| 11-091 | Centers for Independent Living (CILs) Title VI, Part B Reconciliation of Receipts and Expenditures | Excel, PDF |
| 11-092 | On-the-Job (OJT) Job Placement Activity Report (Division of Vocational Rehabilitation) | Word, PDF |
| 11-093 | Outreach Attendance (Office of the Deaf and Hard of Hearing) | Word, PDF |
| 11-094 | User Agreement (Office of the Deaf and Hard of Hearing) | Word, PDF |
| 11-093 | National Deaf-Blind Equipment Distribution Program (NDBEDP) Client Complaint (Office of the Deaf and Hard of Hearing) | Word, PDF |
| 12-006 | Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program |
PDF Instructions PDF 1 - 10 persons PDF 11 - 20 persons |
| 12-123 | Statement of County Prosecutor's Expenditures (Food Stamp Program) | Word, PDF |
| 12-195 | Food Assistance Program Disqualification Consent Agreement | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 12-206 | Application for Disaster Food Stamp Assistance | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 12-207 | Application for Disaster Cash Assistance | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 13-001 | Applicant Medical Report - Confidential |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 13-021 | Physical Functional Evaluation | Word, PDF |
| 13-041 | Child's Medical and Family Background Report | English:
Word,
PDF Other languages (PDF): Cambodian, Korean, Spanish (Word), Spanish, Vietnamese |
| 13-433 | Transfer/Discharge Health Summary (Juvenile Rehabilitation Administration) | Word, PDF |
| 13-585A | Incapacity Range of Joint Motion Chart |
Word,
PDF Other languages (PDF): Tigrigna |
| 13-628 | Involuntary Treatment Act Patient Claim Information | Word, PDF |
| 13-645 | Adult Family Home Injuries and Accidents Log | Word, PDF |
| 13-677 | Naltrexone Authorization | Word, PDF |
| 13-678 Page 1 | Nurse Delegation: Consent for Delegation Process | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 13-678 Page 2 | Nurse Delegation: Instructions for Nursing Task | Word, PDF |
| 13-678A | Nurse Delegation: PRN Medication | Word, PDF |
| 13-678B | Nurse Delegation: Assumption of Delegation | Word, PDF |
| 13-680 | Nurse Delegation: Rescinding Delegation | Word, PDF |
| 13-681 | Nurse Delegation: Change in Medical Orders | Word, PDF |
| 13-690 | Medical Services Authorization (Juvenile Rehabilitation Administration) | Word, PDF |
| 13-692A | Boarding Home Dementia Screening Tool | Word, PDF |
| 13-712 | Medicaid Personal Care Client RSN Transmittal | Word, PDF |
| 13-713 | Fast Track Service Agreement | Word, PDF |
| 13-720 | Suboxone Authorization | Word, PDF |
| 13-734 | Documentation of First Use of Medicaid Benefits (DDA) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 13-737 | Washington Medicaid Integration Partnership (WMIP) AI/AN Exemption/Disenrollment Request | Shana, PDF |
| 13-738 | DDA / CA Request to Cost Share | Word, PDF |
| 13-749 | Campral Authorization (Division of Behavioral Health and Recovery) | Word, PDF |
| 13-750 | Suboxone Exemption Request (Division of Behavioral Health and Recovery) | Word, PDF |
| 13-776 | Nursing Services Referral | Word, PDF |
| 13-784 | Nursing Services Assessment | Word, PDF |
| 13-791 | Vivitrol IM Physician Prior Authorization | Word, PDF |
| 13-830 | ICF/ID Admissions Review Team Checklist | Word, PDF |
| 13-851 | Psychiatric Referral Summary | Word, PDF |
| 13-851A | Psychoactive Medication Treatment Plan | Word, PDF |
| 13-851C | Psychoactive Medication Treatment Plan Annual Continuation of Medication | Word, PDF |
| 13-865 | Psychological/Psychiatric Evaluation |
Word,
PDF PDF Guidelines |
| 13-893 | Nurse Delegation: Request For Additional Units | Word, PDF |
| 13-899 | Review of Medical Evidence | Word, PDF |
| 13-901 | Buprenorphine Authorization for Pregnancy | Word, PDF |
| 13-903 | DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration) | Word, PDF |
| 14-001 | Application for Benefits | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Bosnian, Cambodian, Chinese, French, Indonesian, Korean, Laotian, Russian, Somali, Spanish, Trukese, Vietnamese |
| 14-012 | Consent | English: Word, PDF Other languages (PDF): Albanian, Amharic, Arabic, Armenian, Bosnian, Bulgarian, Burmese, Cambodian, Chinese, Farsi, Finnish, French, German, Hindi, Hmong, Hungarian, Ilocano, Indonesian, Japanese, Karen, Korean, Kurdish, Laotian, Marathi, Marshallese, Mien, Mongolian, Nepali, Oromo, Polish, Portuguese, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Sudanese, Swahili, Tagalog, Thai, Tigrigna, Tongan, Trukese, Turkish, Ukrainian, Urdu, Vietnamese |
| 14-050 | Statement of Health, Education, and Employment | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-057 | Child Support Referral | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Cantonese, Chinese, Farsi, French, Italian, Ilocano, Japanese, Korean, Laotian, Marshallese, Mien, Mongolian, Norwegian, Portuguese, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Thai, Trukese, Ukrainian, Vietnamese |
| 14-057B | Noncustodial Parent Child Support Enforcement Application | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Korean, Somali, Spanish, Tigrigna |
| 14-068 | Financial Statement (Division of Vocational Rehabilitation) | English:
Word,
Excel,
PDF Other languages (PDF): English, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-076 | Change of Circumstances | English: Word, PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-078 | Eligibility Review | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, French, Haitian-Creole, , Indonesian, Japanese, Korean, Laotian, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Trukese, Ukrainian, Vietnamese |
| 14-084 | Financial/Social Services Communications | Word, PDF |
| 14-113 | Your Rights and Responsibilities | English:
Word,
PDF Other languages (PDF): Albanian, Amharic, Arabic, Armenian, Balochi, Bengali, Bulgarian, Burmese, Cambodian, Chinese, Czech, Estonian, Farsi, Finnish, French, German, Haitian-Creole, Hebrew, Hindi, Hmong, Hungarian, Ilocano, Italian, Japanese, Karen, Kirundi, Korean, Laotian, Latvian, Nepali, Marshallese, Mongolian, Oromo, Pashtu, Polish, Portuguese, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Tamil, Thai, Tibetan, Tigrigna, Tongan, Trukese, Turkish, Ukrainian, Urdu, Vietnamese |
| 14-118A | ADATSA Incapacity Decision/Disposition | Word, PDF |
| 14-144A | Medical Disability Decision | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Armenian, Burmese, Cambodian, Chinese, Farsi, Hmong, Korean, Laotian, Mongolian, Nepali, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Tigrigna, Thai, Turkish, Ukrainian, Vietnamese |
| 14-151 | Request for DDA Eligibility Determination | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, German, Korean, Laotian, Polish, Romanian, Russian, Samoan, Somali, Spanish Word, Spanish, Swahili, Tagalog, Vietnamese |
| 14-155 | Senior Citizens Service Application |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish Word, Spanish, Vietnamese |
| 14-162 | Veteran's Referral | Word, PDF |
| 14-191 | Personal Employment Plan (PEP) - Application and Referrals (Refugee Assistance) | Word, PDF |
| 14-222 | Statement of Collateral Information | English:
Word,
PDF,
Translated Summary Other languages (PDF): Albanian, Amharic, Arabic, Bengali, Cambodian, Chinese, Farsi, French, Indonesian, Japanese, Korean, Kurdish, Laotian, Nepali, Punjabi, Romanian, Russian, Somali, Spanish, Tagalog, Tigrigna, Trukese, Vietnamese |
| 14-223 | Statement from School |
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Korean, Laotian, Mongolian, Oromo, Portuguese, Romanian, Russian, Samoan, Somali, Spanish, Swahili, Tagalog, Ukrainian, Vietnamese |
| 14-224 | Statement from Landlord/Manager | English:
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Karen, Korean, Laotian, Mien, Romanian, Russian, Somali, Spanish, Tagalog, Tigrigna, Tongan, Urdu/a>, Vietnamese |
| 14-225 | Acknowledgement of Services | English:
Word,
PDF Other languages (PDF): Albanian, Amharic, Arabic, Bosnian, Cambodian, Chinese, Farsi, Hindi, Ilocano, Indonesian, Italian, Japanese, Korean, Kurdish, Laotian, Mien, Marshallese, Nepali, Oromo, Polish, Punjabi, Romanian, Russian, Samoan, Serbo Croatian, Somali, Spanish Word, Spanish, Tagalog Tigrigna, Tongan, Turkish, Ukrainian, Urdu, Vietnamese |
| 14-238 | Client Income Report | Word, PDF |
| 14-245 | Education List Checklist (Juvenile Rehabilitation Administration) | Word, PDF |
| 14-251 | Statement of Applicant / Recipient or Other Person (Burial Fund Provision SSI Related) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-251A | Statement of Applicant / Recipient or Other Person (Irrevocable Burial Fund Provision SSI Related) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-252 | Employment Verification | English: Word, PDF Other languages (PDF): Amharic, Arabic, Armenian, Bengali, Burmese, Cambodian, Chinese, Farsi, French, Haitian-Creole, Hindi, Hmong, Farsi, French, Ilocano, Gujarati, Japanese, Kirundi Korean, Kurdish, Laotian, Marshallese, Mongolian, Nepali, Oromo, Portuguese, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Trukese, Turkish, Ukrainian, Vietnamese |
| 14-264 | Application for Telecommunications Equipment | Word, PDF |
| 14-281 | Source of Funds Application for Child in Placement | Word, PDF |
| 14-293 | Title IVE Initial Eligibility Determinations: Income Calculation Worksheet (Children's Administration) | Excel, PDF |
| 14-299 | ADATSA/Adult Assessment Referral | Word, PDF |
| 14-300 | Level One Pre-Admission Screening and Resident Review (PASRR) | Word, PDF |
| 14-303 | Specialized Services Assessment (OBRA) | Word, PDF |
| 14-310 | Client Status Change Report | Word, PDF |
| 14-311 | Assessment Center Summary for ADATSA | Word, PDF |
| 14-311A | Assessment Center Summary for TANF | Word, PDF |
| 14-313 | Client Notice of ADATSA Eligibility | Word, PDF |
| 14-314 | Release of Confidential Information for Assessment Center and ADATSA/Adult Treatment Providers | Word, PDF |
| 14-319 | Title IVE Initial Eligibility Determination for an Adoption Support Application (CA) | Word, PDF |
| 14-332 | Disability Assessment | Word, PDF |
| 14-338 | Level II: Initial Psychiatric Evaluation Summary Information | Word, PDF |
| 14-339 | Level II: Follow-Up or Significant Change Psychiatric Evaluation Summary Information | Word, PDF |
| 14-349 | Protective Payee Assessment | English:
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Korean, Laotian, Marshallese, Punjabi, Russian, Somali, Spanish, Vietnamese |
| 14-352 | Initial Security Classification Assessment | English:
Word,
PDF Other languages (PDF): Burmese |
| 14-369 | Instructional Staff Application (NATCEP) | Word, PDF |
| 14-370 | Nursing Assistant Training Program (NATCEP) Application for Program Director | Word, PDF |
| 14-371 | Nursing Assistant Training Program (NATCEP) Application for Approval | Word, PDF |
| 14-381 | WorkFirst Individual Responsibility Plan | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Bengali, Bhutanese, Burmese, Cambodian, Chin, Chinese, Farsi, French, Karen, Kirundi, Korean, Laotian, Macedonian, Mien, Mongolian, Pashtu, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Swahili, Tagalog, Thai, Tigrigna, Tongan, Urdu, Vietnamese |
| 14-393 | Statement of Shared Living Arrangement | English:
Word,
PDF Other languages (PDF): |
| 14-401 | Notification of Address Disclosure Request - Part 1 | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 14-401A | Notification of Address Disclosure Request - Part 2 | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 14-402 | Notice to Parents (WorkFirst) |
English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese |
| 14-405 | HCS/AAA Planned Action Notice | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Bosnian, Bulgarian, Burmese, Cambodian, Chinese, Farsi, Finnish, Hungarian, Ilocano, Japanese, Karen, Korean, Kurdish, Laotian, Nepali, Oromo, Pashtu, Polish, Punjabi, Romanian, Russian, Samoan, Somali, Spanish, Tagalog, Tigrigna, Tongan, Turkish, Ukrainian, Urdu, Vietnamese |
| 14-412 | ADATSA Request for Exception to Rule | Word, PDF |
| 14-413 | Level II: Invalidation Statement, Statement and Criteria of Non-Completion | Word, PDF |
| 14-413A | Level II: Invalidation Statement: Documentation for Interrupted Evaluation | Word, PDF |
| 14-416 | Eligibility Review for Long Term Care Benefits (Aging and Long-Term Support Administration | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Hungarian Italian Korean, Laotian, Polish, Russian, Somali, Spanish, Vietnamese |
| 14-417 | Child Care Subsidy Programs (CCSP) Application | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, French, Karen, Kayah, Korean, Laotian, Oromo, Russian, Somali, Spanish, Trukese, Vietnamese |
| 14-417A | In-Home/Relative Pending Letter (Child Care Subsidy Program) | English:
Word,
PDF Other languages (PDF): Arabic, Burmese, Cambodian, Chinese, French-Creole, Kirundi Korean, Laotian, Nepali, Oromo, Punjabi, Russian, Somali, Spanish, Sudanese, Swahili, Trukese, Ukrainian, Vietnamese |
| 14-423 | Diagnostic Mental Health Screen | Word, PDF |
| 14-426 | Protective Payee Payment Plan, Case Assignment, and Closure Notice | English: Word, PDF Amharic, Cambodian, Chinese, Farsi, Korean, Laotian, Marshallese, Russian, Somali, Spanish, Vietnamese |
| 14-427 | Teen Parent Living Assessment PDF Instructions |
Word, PDF |
| 14-431 | Medical/Dental Services Authorization | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-432 | Direct Deposit Enrollment PDF Instructions |
English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Farsi, Korean, Laotian, Russian, Serbo-Croatian, Spanish, Tagalog, Tamil, Vietnamese |
| 14-434 | Title IV-E Requirements for Out of State Foster Care Payments (Children's Administration) | Word, PDF |
| 14-435 | Provider Employment Eligibility Verification (Children's Administration) | Word, PDF |
| 14-436 | Statement of Adult Acting in Loco Parentis (As a Parent) | Word, PDF |
| 14-438 | Stop Work | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian,, Russian, Somali, Spanish, Vietnamese |
| 14-439 | WASHCAP Application | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-440 | Non-Profit Organization Application for Reconditioned Telecommunications Equipment | Word, PDF |
| 14-443 | Financial/Social Services Communication | Word, PDF |
| 14-444 | Child Health and Education Tracking Screening Report |
Word,
PDF Other languages (PDF): Burmese, Cambodian, Chinese, Karen, Korean, Laotian, Marshallese, Russian, Somali, Spanish, Vietnamese |
| 14-445 | Nursing Assistant Training Program (NATCEP) Application for Renewal | Word, PDF |
| 14-446 | Declaration of Financial Status (Children's Administration) | Word, PDF |
| 14-448 | ADATSA Request for Exception to Contract | Word, PDF |
| 14-452 | Financial Worksheet (Children's Administration) | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-453 | Protective Payee Decision | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-454 | Estate Recovery Fact Sheet | English:
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Farsi, Hindi, Hmong, Ilocano, Indonesian, Korean, Laotian, Nepalese, Oromo, Polish, Punjabi, Romanian, Russian, Samoan, Serbo Croatian, Somali, Spanish, Tagalog, Tigrigna, Tongan, Ukrainian, Vietnamese |
| 14-459 | Eligible Conditions Specific to Age and Type of Evidence (Division of Developmental Disabilities) | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, German, Korean, Laotian, Polish, Romanian, Russian, Samoan, Somali, Spanish, Spanish Word, Swahili, Tagalog, Vietnamese |
| 14-460 | Notice of Insufficient Information (Division of Developmental Disabilities) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-462 | Epilepsy Verification Request (Division of Developmental Disabilities) | Word, PDF |
| 14-463 | Waiver Transportation Record (DDA) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-465 | Sources For Eligibility Information (DDA) | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Shana, Spanish, Vietnamese |
| 14-467 | Mid-Certification Review | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-473 | ICAP Letter | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-474 | Shared Planning Meeting | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Hmong, Korean, Kurdish, Laotian, Marshallese, Punjabi, Russian, Somali, Spanish Word, Spanish, Swahili, Tagalog, Tigrigna, Vietnamese |
| 14-475 | Appointment Letter for Division of Child Support (DCS) Good Cause Determination | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, French, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-478 | Treatment Verification Request | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-479 | DASA Target Data Element - Gain Short Screening Setup | Word, PDF |
| 14-484 | Nurse Delegation: Nursing Visit | Word, PDF |
| 14-485 | GAIN-SS (Mental Health) | English:
Word,
PDF Other languages (PDF): Russian, Russian Word, Spanish, Spanish Word, |
| 14-489 | SSIF Introduction Letter | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Punjabi, Russian, Somali, Spanish, Vietnamese |
| 14-491 | NSA Representative Checklist For AAG Authorization | Word, PDF |
| 14-492 | Assessment Meeting Wrap-up | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-493 | Requirement to Identify a Representative | English:
Word,
PDF, Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 14-494 | Chronic Care Management Health
Action Plan PDF Instructions |
Word, PDF |
| 14-494A | Chronic Care Management Health Action Plan Continuation | Word, PDF |
| 14-495 | Naturalization Letter | English:
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Ilocano, Korean, Laotian, Russian, Serbo-Croatian, Somali, Spanish, Vietnamese |
| 14-496 | Naturalization Appointment Letter | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-501 | Community Resource Declaration | Word, PDF |
| 14-502 | SSI Hearing Denial | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-503 | Interim Assistance Reimbursement Agreement Cover | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Croatian, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Vietnamese |
| 14-505 | Application for Deaf-Blind Communicator (DBC) | Word, PDF |
| 14-510 | Respite Provider Policy Agreement | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish, |
| 14-512 | Application For Respite Provider Approval | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish, |
| 14-513 | Respite Care Provider Cover Letter | English:
Word,
PDF Other languages (PDF): Spanish Word Spanish, |
| 14-514 | Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center | English:
Word,
PDF Other languages (PDF): Spanish Word Spanish, |
| 14-515 | Notice and Finding of Responsibility | English:
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-517 | DSHS Letter Requesting Non Work SSN | Word, PDF |
| 14-520 | Your DSHS Cash or Food Assistance Benefits | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Bengali, Cambodian, Chinese, Estonian, Hindi, Hmong, Korean, Laotian, Marshallese, Russian, Serbo-Croatian Somali, Spanish, Swahili Tagalog, Tigrigna, Ukrainian, Vietnamese |
| 14-521 | Your Rights (Home and Community Services) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Japanese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Ukrainian, Vietnamese |
| 14-522 | Chemical Dependency Good Cause Letter | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-523 | Pierce County Basic Food Application PILOT | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-524 | Yakima County Basic Food Application PILOT | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-525 | Incapacity Review for Medical Care Services | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, French, Korean, Laotian, Nepali, Punjabi, Romanian, Russian, Somali, Spanish, Swahili, Tigrigna, Ukrainian, Vietnamese |
| 14-526 | Chemical Dependency Treatment Verification Request | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-527 | Medical Care Services Case Plan | English:
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Tigrigna, Vietnamese |
| 14-528 | Chemical Dependency NonCooperation | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-529 | Chemical Dependency Requirement | English:
Word,
PDF Other languages (PDF): Burmese, Cambodian, Chinese, Karen, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-530 | Disability Review | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Dinka, Korean, Laotian, Punjabi, Russian, Somali, Spanish, Thai, Tigrigna, Vietnamese |
| 14-531 | Education and Training Voucher (ETV) Program andPassport to College Promise Scholarship 2013 - 2014 Application | Word, PDF |
| 14-532 | Authorized Representative | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 14-533 | National Deaf-Blind Equipment Distribution Program Application PDF Instructions , Text Instructions |
Word, Text, PDF |
| 14-533LP | National Deaf-Blind Equipment
Distribution Program Application (Large Print) PDF Instructions |
Word, PDF |
| 14-534 | SDCP Eligibility Checklist (Home and Community Services) | Word, PDF |
| 15-031 | Notice of Action - Adult Residential Services | Word, PDF |
| 15-051 | Individual Provider Time Sheet | English:
Word,
PDF Other languages (PDF): Arabic, Bosnian, Cambodian, Chinese, Farsi, Korean, Laotian, Punjabi, Russian, Samoan, Somali, Spanish Word, Spanish, Tagalog, Vietnamese |
| 15-092 | ICPC Placement Request | Word, PDF |
| 15-093 | Interstate Compact on the Placement of Children Report on Child's Placement Date or Change of Placement | Word, PDF |
| 15-168 | Assessment For Specialized Services (Age 13 and Older) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 15-170A | Child's Assessment For Specialized Services (For children birth through age 12) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 15-184 | Volunteer Chore Service Referral | Word, PDF |
| 15-209C | Visiting Plan | English:
Word,
PDF Other languages (PDF): Cambodian, Serbo-Croatian |
| 15-215 | AFH Quality Improvement Visit Assessment | Word, PDF |
| 15-243 | Social Services Case Reading Guide | Word, PDF |
| 15-245 | LEP Client Service Record (Limited English Proficient) | Word, PDF |
| 15-247 | Working Connections Child Care (WCCC) Termination Notice | English:
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Farsi, Korean, Laotian, Marshallese, Russian, Somali, Spanish, Trukese, Vietnamese |
| 15-247A | Working Connections Child Care (WCCC) Denial Notice | English:
Word,
PDF Other languages (PDF): Amharic, Arabic, Cambodian, Chinese, Karen, Korean, Laotian, Russian , Somali, Spanish, Vietnamese |
| 15-252 | DRW Access Request Checklist | Word, PDF |
| 15-255 | Medicaid Personal Care Provider Experience and Training Statement (Children's Administration) | Word, PDF |
| 15-258 | Safety Assessment | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-259 | Safety Plan | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-260 | Parent Information Sheet For Shared Planning Meetings and Staffings | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish Word, Spanish, Vietnamese |
| 15-266 | CPT Staffing Recommendations | English:
Word,
PDF Other languages (PDF): Vietnamese |
| 15-268 | CPT Case Presentation Summary |
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 15-274 | Assistance Available Schedule (DDA) | Word, PDF |
| 15-276 | Personal Information (Childrens Administration) | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 15-280 | Unlicensed Caregiver Placement Checklist (Children's Administration) |
Word,
PDF Other languages (PDF): Spanish Word, Spanish |
| 15-281 | Placement Agreement (Children's Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 15-282a | Request for Enrollment in Developmental Disability Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change From One DDA HCBS Waiver to Another | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-286 | Reference Questionnaire (Children's Administration) | English:
Word,
PDF Other languages (PDF): Arabic, Korean, Somali, Spanish Word, Spanish, Vietnamese, |
| 15-290 | Notification of Annual Assessment Review | Word, PDF |
| 15-291 | Client Notification of Annual Assessment Meeting | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-295 | Waiver Individual Support Plan Meeting Survey | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-300 | Child Information/Placement Referral | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish, |
| 15-304 | HCBS Waiver Enrollment Database Update (DDA) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-308 | Missing Child Staffing | Word, PDF |
| 15-309 | Returning Child De-Briefing | Word, PDF |
| 15-313 | Caregiver's Report to the Court | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 15-314 | Client Necessary Supplemental Accommodation Representative Requirement Checklist | Word, PDF |
| 15-318 | DDA Crisis Diversion Bed Referral and Intake Information | Word, PDF |
| 15-322 | Long Term Care Agreement For Foster Parents or Relative Caregivers | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish, Vietnamese, |
| 15-323 | Checklist For Approval Long Term Care Agreement For Foster Parents or Relative Caregivers | Word, PDF |
| 15-324 | Guardianship Approval Checklist | Word, PDF |
| 15-331 | Annual Assessment Checklist (Developmental Disability Administration) | Word, PDF |
| 15-339 | Foster Care to 21 Program Placement Agreement | Word, PDF |
| 15-342 | Notice of Exception to Rule Decision | English:
Word,
PDFF Other languages (PDF): Cambodian, Chinese, Kirundi, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Swahili, Vietnamese |
| 15-344 | Private Duty Nursing Logs and Skilled Nursing Tasks Log | |
| 15-345 | Community Services Office (CSO)/Developmental Disability Administration (DDA) Communication | Word, PDF |
| 15-356 | DDA Community Protection Program Chaperone Agreement | Word, PDF |
| 15-357 | Residential Services Opening Description | Word, PDF |
| 15-358 | Client Referral Information | Word, PDF |
| 15-359 | Child's Physical Description | Word, PDF |
| 15-360 | Residential Services Capacity Profile | Word, PDF |
| 15-361 | Individual and Family Services Program Request List - No Response | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-362 | Concurrent TANF Benefits / Family Reunification Notice of Removal from TANF Home (Children's Administration) | Word, PDF |
| 15-365 | Community Protection Treatment Worksheet Quarterly Review | Word, PDF |
| 15-366 | Change of Address (DDA) | Word , PDF |
| 15-367 | Administrative Review Request For Crime and/or Negative Action | Word, PDF |
| 15-368 | Education and Training Voucher (ETV) Program Participation Agreement | Word, PDF |
| 15-369 | Educational and Training Voucher (ETV)Program Renewal Application | Word, PDF |
| 15-370 | Education and Training Voucher (ETV) Program Payment Request | Word, PDF |
| 15-372 | Enumeration Referral | Word, PDF |
| 15-374 | Physician Certification For Child/Youth With Developmental Disabilities to Maintain Their Permanent Residence | Word, PDF |
| 15-375 | Home Study Referral for Contracted Services | Word, PDF |
| 15-376 | Skin Observation Protocols | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-377 | Educational and Training Voucher (ETV) Program Running Start Application | Word, PDF |
| 15-379 | Vendor Request for Staff Add-On (DDA) | Word, PDF |
| 15-380 | Individual and Family Services Assessment Worksheet | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 15-381 | Respite Assessment Worksheet | Word, PDF |
| 15-382 | Positive Behavior Support Plan (PBSP) | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish, |
| 15-383 | Functional Behavioral Assessment (FA) | English:
Word,
PDF Other languages (PDF): Spanish Word, Spanish, |
| 15-384 | Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA) | Word, PDF |
| 15-385 | Provider Consent For Use of Restrictive Procedures Requiring an ETP | Word, PDF |
| 15-387 | Respite Application - Licensed Staffed Residential/Foster Home | Word, PDF |
| 15-388 | Alternative Living Review and Evaluation | Word, PDF |
| 15-398 | Medically Intensive Children's Program (MICP) Application | Word, PDF |
| 15-402 | Notice to Foreign Consulate of Child Protection Proceedings | Word, PDF |
| 15-411 | Licensing Waiver/Administrative Approval | Word, PDF |
| 15-418 | Attestation Form - Request For Exception to Rule For Disqualifying Drug Crimes | Word, PDF |
| 15-419 | Refusal of Services Statement | Word, PDF |
| 15-420 | Request For ICF/ID Admission | Word, PDF |
| 15-422 | No Paid Services Group | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Ukrainian, Spanish, Vietnamese |
| 15-424 | Staffed Residential Cost of Care Adjustment Request | Word, PDF |
| 15-428 | Protective Action(s) Plan (Children's Administration) |
Word,
PDF Other languages (PDF): Spanish, Spanish Word, Tagalog |
| 15-430 | Seasonal Child Care (SCC) Termination Notice | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 15-430A | Seasonal Child Care (SCC) Denial Notice | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian , Somali, Spanish, Vietnamese |
| 16-072 | NonAssistance Support Enforcement Information | English:
PDF Other languages (PDF): Amharic, Arabic, Burmese, Cambodian, Cantonese, Chinese, Farsi, French, Hmong, Italian, Japanese, Korean, Laotian, Marshallese, Portuguese, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Tigrigna, Trukese, Ukrainian, Vietnamese |
| 16-140 | DUI / PC Assessment Report (DASA) | Word, PDF |
| 16-169 | ICW Quarterly Report | Word, PDF |
| 16-170 | Nursing Assistant Training Program (NATCEP) Curriculum Verification of Requirements - 42 CFR 483.152 and WAC 246-841-400 and 246-841-490 | Word, PDF |
| 16-172 | Your Rights and Responsibilities When You Receive Services Offered by Aging and Long-Term Support Administration | English:
Word,
PDF Other languages (PDF): Albanian, Amharic, Arabic, Bosnian, Bulgarian, Cambodian, Chinese, Farsi, Finnish, Hindi, Ilocano, Indonesian, Japanese, Korean, Laotian, Mien, Nepali, Oromo, Punjabi, Romanian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Spanish Word, Tagalog, Thai, Tigrigna, Tongan, Turkish, Ukrainian, Vietnamese |
| 16-179 | Reference Cover Letter (Childrens Administration) | English:
Word,
PDF Other languages (PDF): Arabic, Korean, Somali, Spanish Word, Spanish, |
| 16-180 | CCSP Rights and Responsibilities (Child Care Subsidy Programs) | English:
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Farsi, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 16-181 | A Guide to In-Home Relative Child Care | English:
PDF Other languages (PDF): Arabic, Burmese, Cambodian, Chinese, Dinka, French, Korean, Laotian, Marshallese, Nepali, Nuer, Polish, Punjabi, Russian, Serbo-Croatian, Somali, Spanish, Swahili, Trukese, Tagalog, Ukrainian, Vietnamese |
| 16-182 | Guidelines for Completing the ICAP/SIB-R Adaptive Behavior Scale (Childrens Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 16-191 | SOLA Vehicle Trip Log (Division of Developmental Disabilities) | Word, PDF |
| 16-192 | Intake Cover Letter (Division of Developmental Disabilities) | English:
Word ,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 16-193 | Nurse Aide Registry Inquiry (ADSA) | Word , PDF |
| 16-194 | DDA Specialty Training Sign-Up Sheet | Word , PDF |
| 16-195 | Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative | English:
Word,
PDF Other languages (PDF): Amharic, Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 16-197 | Boarding Home Policies and Procedures Attestation | Word, PDF |
| 16-199 | New Case/Resource Manager Technology Training Checklist | Word, PDF |
| 16-200 | Memo to Provider for Behavior Support, Counseling, and Consultation Services | Word, PDF |
| 16-202 | 5-Day Investigation Report | Word, PDF |
| 16-202A | Plan of Correction (5-Day Investigation) | Word, PDF |
| 16-203 | SIS Rating Key | English: PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Vietnamese |
| 16-204 | Fire Evacuation Plan | English:
Word,
PDF Other languages (PDF): Arabic, Korean, Spanish Word, Spanish, |
| 16-205 | Personal Emergency Plan Information | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 16-213 | Verification of Legal Status | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 16-214 | Administrative Hearing Docket Cover Sheet | Word, PDF |
| 16-220 | SOLA Incident Report (DDA) | Word, PDF |
| 16-221 | Children's Respite in Licensed Staffed Residential/Foster Home Settings | Word, PDF |
| 16-222 | Accessing Out-of-Home Respite Services | |
| 16-223 | RHC Visiting Professional Sign-In Record | Word, PDF |
| 16-225 | Respite Provider Checklist | Word, PDF |
| 16-229 | Educational Resources for Youth in Foster Care Through DSHS in Washington State or a Tribal Child Welfare Agency | |
| 16-230 | Children's Residential Services | Word, PDF |
| 16-231 | Permanency Planning Benefits and Limitations |
PDF Other languages (PDF): Spanish |
| 16-232 | Medicaid Provider Profile Request | Word, PDF |
| 16-233 | Mentor Program Referral and Guidelines | Word, PDF |
| 16-234 | Vulnerable Adult Statement of Rights |
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 17-011 | Forms and Publications Request PDF Instructions |
Word, PDF |
| 17-041 | Request for Records | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 17-041A | Request for Children's Administration Records | English:
Word,
PDF Other languages (PDF): Spanish, Spanish Word |
| 17-063 | Authorization | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Korean, Laotian, Mien, Punjabi, Russian, Somali, Spanish, Tigrigna, Vietnamese |
| 17-116 | AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion | Word, PDF |
| 17-123 | Spoken Language Interpreter Service
Appointment Record PDF Instructions |
Word, PDF |
| 17-123A | Request for Sign Language Interpreter | Word, PDF |
| 17-155 | Sign Language Interpreter Registration | Word, PDF |
| 17-155A | Sign Language Interpreter Registration Renewal | Word, PDF |
| 17-180 | Personal Information Release (Economic Services Administration) | Word, PDF |
| 17-194 | Request for Mental Health Service Information | Word, PDF |
| 17-211 | Authorization for SSI Facilitation Records (Economic Services Administration) |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 18-078 | Application for Nonassistance Support Enforcement Services | English:
Word,
PDF Other languages (PDF): Arabic, Burmese, Cambodian, Cantonese, Chinese, Farsi, French, Hmong Italian, Japanese, Korean, Laotian, Portuguese, Punjabi, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Ukrainian, Vietnamese |
| 18-097 | Statement of Resources and Expenses | English:
Word,
PDF Other languages (PDF): Amharic, Armenian, Arabic, Bengali, Burmese, Cambodian, Chinese, Chiu Chow, German, Ilocano, Karen, Marshallese, Mongolian, Nepali, Oromo, Punjabi, Russian, Somali, Spanish, Swahili, Thai, Tigrigna, Trukese, Vietnamese |
| 18-235 | Initial payment (Interim Assistance Reimbursement Authorization) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, , Korean, Laotian, Russian, Serbo-Croatian, Somali, Spanish, Vietnamese |
| 18-334 | How You Must Help with Child SupportCollection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 18-398A | Vendor Overpayment Notice | Word, PDF |
| 18-399 | Social Service Incorrect Payment Computation | English:
Word,
Excel,
PDF Other languages (PDF): Cambodian, Chinese, French, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 18-400 | Foster Parent Reimbursement Claim and Checklist | English:
Word,
PDF Other languages (PDF): Spanish Shana, Spanish, |
| 18-400A | Third Party Claim Checklist | Word, PDF |
| 18-433 | Declaration of Support Payments | English:
Word,
PDF Amharic, Arabic, Burmese, Cambodian, Chinese, Italian, Korean, Laotian, Mien, Mongolian, Oromo, Portuguese, Romanian, Russian, Samoan, Somali, Spanish, Tagalog, Trukese, Vietnamese |
| 18-463 | New Hire Reporting Methods and Instructions | Word, PDF |
| 18-483 | Employer Payment Identification Instructions | English:
Word,
PDF Other languages (PDF): Russian |
| 18-484 | Automatic Payment Authorization and Electronic Funds Transfer Information | English:
Word,
PDF Other languages (PDF): Punjabi, Russian, Spanish, Telugu, Vietnamese |
| 18-503 | Financial Information Sheet | English:
Word,
PDF Other languages (PDF): Spanish |
| 18-504 | Financial Information Sheet Instructions | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Spanish, Vietnamese |
| 18-544 | Transmittal of Resident Personal Funds | Word, PDF |
| 18-555 | Financial Information Sheet | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 18-627 | SSP Client Overpayment Notice (State Supplementary Program)(DDA) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Romanian, Russian, Somali, Spanish Shana, Spanish, Vietnamese |
| 18-691 | Client Responsibility Information | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 18-692 | Client Responsibility Notice | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish Word, Spanish, Vietnamese |
| 18-701 | Request for Income Information for Purposes of Entering a Child Support Order | English:
Word,
PDF Other languages (PDF): Spanish, |
| 19-074 | Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation) | Word, PDF |
| 19-227 | Juvenile Accountability Incentive Block Grant (JAIBG) Financial Report (JRA) | Word, PDF |
| 19-228 | Juvenile Accountability Incentive Block Grant (JAIBG) Progress Report | Word, PDF |
| 19-231A | Individual Site Billing Details | Excel, PDF |
| 19-231B | Program Billing Details | Excel, PDF |
| 19-231C | Program Billing Details Continuation | Excel, PDF |
| 19-232 | Academic Cost | Excel, PDF |
| 19-232A | Academic Cost Continuation | Excel, PDF |
| 20-003 | Psychosocial/Diagnostic Face Sheet (Juvenile Rehabilitation) | Word, PDF |
| 20-037 | Change Report (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-188 | Authorized Leave Order (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 20-190 | Personal Property Inventory (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-191 | Youth Personal Property Transmittal (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-198 | Sentencing Worksheet (Juvenile
Rehabilitation Administration) PDF Instructions |
Word, PDF |
| 20-199 | Room and Isolation Confinement Record (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-201 | Authorized Leave Approval (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-205 | Plethysmograph Examination Informed Consent (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-207 | Incident Review (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-212 | Transition Report (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-213 | Response to Transition Report/Initial Service Plan (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-214 | Youth Suicide Precaution Tracking (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-215 | Law Enforcement Records Request (Juvenile Rehabilitation) | Word, PDF |
| 20-216 | School Behavior Records Request (Juvenile Rehabilitation) | Word, PDF |
| 20-217 | Predisposition Diagnostic Report (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-218 | Diagnostic Record of Official Action (Juvenile Rehabilitation) | Word, PDF |
| 20-218A | Diagnostic/Placement Record of Official Action (Juvenile Rehabilitation) | Word, PDF |
| 20-219 | Request for Exception to Standards (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-220 | Supervisory Case Review (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-222 | Sexual Aggression Vulnerability Youth Assessment (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-223 | Parent/Guardian Notification (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-224 | Community Facility Violation/Incident Report (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-225 | Claim for Damages (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-226 | Claim for Damages (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 20-227 | Wanted Person Notice of Cancellation (Juvenile Rehabilitation Administration) | Word , PDF |
| 20-228 | Conditions of School Involvement School Agreement (JRA Community Facility) | Word, PDF |
| 20-228A | Conditions of School Involvement School Agreement (Community Facility) | Word, PDF |
| 20-229A | Conditions of Employment Employer Agreement (Community Facility) | Word, PDF |
| 20-229B | Conditions of Treatment Provider Agreement (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-230 | Juvenile Volunteer Project Supervisor Agreement (JRA Community Facility) | Word, PDF |
| 20-231 | Institutional Substance Abuse Treatment Services Summary (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-232 | Policy Proposal (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-233 | Policy Feedback (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-234 | Youth Complaint - Appeal Request (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-235 | SchoolNotification (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-236 | Notification and Legal Requirements (Juvenile Rehabilitation Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Laotian, Spanish, Vietnamese |
| 20-238 | Administrative Report of Incidents (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-240 | Administrative Reports of Incidents (Parole Programs) (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-247 | Youth Media Release (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-250 | Consent for Release to Parent/Guardian/Involved Individual (Juvenile Rehabilitation) | Word, PDF |
| 20-252 | Community Program Eligibility (Juvenile Rehabilitation) | Word, PDF |
| 20-253 | Polygraph Notification (Juvenile Rehabilitation Administration) | Word, PDF |
| 20-254 | Treatment Summary (Juvenile Rehabilitation) | Word, PDF |
| 20-254A | Treatment Summary - Additional Target Behaviors and Skills (Juvenile Rehabilitation) | Word, PDF |
| 20-256 | Integrated Treatment Plan (Juvenile Rehabilitation) | Word, PDF |
| 20-258 | Stored Property Inventory (Juvenile Rehabilitation) | Word, PDF |
| 20-259 | Request for Community Placement Administrative Override (Juvenile Rehabilitation) | Word, PDF |
| 20-260 | Request for Warrant Check on JRA Youth (Juvenile Rehabilitation) | Word, PDF |
| 20-265 | Client History Review (Juvenile Rehabilitation) | Word, PDF |
| 20-270 | Substance Abuse Screen (SAS) (Juvenile Justice and Rehabilitation Administration) PDF Instructions |
Word, PDF |
| 20-271 | JRA Integrated Treatment Assessment (Juvenile Justice and Rehabilitation Administration) PDF Instructions |
Word, PDF |
| 20-273 | Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Spanish Word, Vietnamese |
| 21-053 | Important Phone Numbers and Emergency Response Information (Adult Family Home) | Word, PDF |
| 21-057 | SOLA Maintenance/Repair Log (Division of Developmental Disabilities) | Word, PDF |
| 21-058 | SOLA Monthly Vehicle Checklist (Division of Developmental Disabilities) | Word, PDF |
| 21-059 | Children's Staffed Residential Quality Assurance Assessment |
Word,
PDF Other languages (PDF): Spanish, Spanish Word |
| 21-060 | Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment | Word, PDF |
| 23-023 | Business Assessment Questionnaire | Word, PDF |
| 23-027 | 90 Day Review Checklist For Social Workers Staffed Residential Facilities, Group Care Facilities and Child Foster Homes | Word, PDF |
| 23-032 | Washington State Child Abuse and Neglect Findings Request | Word, PDF |
| 23-033 | Child Abuse and Neglect Information Request | Word, PDF |
| 23-034 | Alternative Living Financial Report | Word, PDF |
| 23-035 | CHINS/ARY Report to Juvenile Court | Word, PDF |
| 23-036 | Child Placing Agency Foster Home Licensing Investigation | Word, PDF |
| 23-036a | Child Placing Agency Foster Home Licensing Investigation Interviews | Word, PDF |
| 23-037 | Background Clearance Notification | Word, PDF |
| 27-043 | Contractor Intake | Word, PDF |
| 27-051 | DSHS / Union Contract Decision Process | Word, PDF |
| 27-053 | Paternity Information | English:
Word,
PDF Other languages (PDF): Arabic, Burmese, Cambodian, Chinese, German, Korean, Laotian, Russian, Somali, Spanish, Tagalog, Tigrigna, Ukrainian, Vietnamese |
| 27-056 | Ward of the Court Verification | Word, PDF |
| 27-057 | Voluntary Placement Program Provider Referral Letter (DDA) | Word, PDF |
| 27-059 | Finger Print Appointment | English:
Word,
PDF Other languages (PDF): Arabic, Cambodian, Chinese, Farsi, Korean, Laotian, Russian, Samoan, Serbo-Croatian, Somali, Spanish, Tagalog, Thai, Vietnamese |
| 27-063 | Voluntary Placement Services For Youth (Age 18-21) | Word, PDF |
| 27-076 | Mandatory Reporting of Abandonment, Abuse, Neglect, Exploitation, or Financial Exploitation of a Child or Vulnerable Adult (Developmental Disability Administration) | Word, PDF |
| 27-081 | Employment and Day Program Services Providers: Mandatory Reporting of Abandonment, Abuse, Neglect, Exploitation, or Financial Exploitation of a Child or Vulnerable Adult (Developmental Disability Administration) | Word, PDF |
| 27-082 | Five Day Notice to Move (Children's Administration) | English:
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 27-089 | Fingerprint-Based Background Check Notice |
Word,
PDF Other languages (PDF): Cambodian, Chinese, Korean, Laotian, Russian, Somali, Spanish, Vietnamese |
| 27-093 | School Notification (Children's Administration) | Word, PDF |
| 27-094 | Medical Provider Disclosure Statement (Aging and Long-Term Support Administration) | Word, PDF |
