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Choose search option and begin typing the form #, Washington State Department of Social and Health Services, Aging and Long-Term Support Administration (ALTSA), Developmental Disabilities Administration (DDA), Facilities, Finance and Analytics Administration (FFA), Language Testing and Certification Program, Interview Appointment for Applicant - (DSHS 14-105) Emergencies, RCS Supported Living Infection Prevention Assessment Tool for COVID-19, Phase 1 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services), Phase 2 Higher Education and Workforce Training COVID-19 Requirements (Home and Community Services), Protective Payee Periodic Social Services Report, Able Bodied Adults Without Dependents (ABAWD) Activity Report, Transmittal of Client Funds from the Protective Payee, ALTSA Nurse Delegation Referral and Communication Case / Resource Manager's Request, Adult Family Home Resident Personal Belongings Inventory (Residential Care Services), Request for Exception to Policy (ETP) for Use of Restrictive Procedures (Developmental Disabilities Administration), Background check Identification Verification (Office of Deaf and Hard of Hearing), Companion Home Outside Employment Notification and Review (Developmental Disabilities Administration), Application for Approval of Interpreter and Translator Continuing Education Activity, Statement of Understanding: Mid-Certification Review, Residential Provider's Report of Weapon Ownership in Residential Setting, Additional Information Needed for ILP TANF, Community Instructor Class List Tracking Log, Adult Family Home (AFH) Personnel Changes (Aging and Long-Term Support Administration), DSHS Virtual Classroom Training Application (Home and Community Services), DSHS Virtual Classroom Training Application: Addendum to DSHS 02-714 (Home and Community Services), Rapid Response Request (Residential Care Services, Aging and Long-Term Support Administration), Employee Personal Property Damage/Loss Claim, Agreement on Nondisclosure of Confidential Information - Non-Employee, ESA Non-Dislcosure of Confidential Information Agreement - Non Employee, Confidential Information, Fraud and Abuse, DSHS Notice of Privacy Practices for Client Medical Information, DSHS Notice of Privacy Practices for Client Medical Information without Acknowledgement, DSHS Notice of Privacy Practices for Client Medical Information: DSHS HIPAA Covered Programs, Witness Report of Possible Client Assault (Per RCW 72.01.045, RCW 74.04.790), Employee / Contractor Awareness IRS Safeguard Training Certification, Medication Administration Competency Assessment Tool, Character, Competence, and Suitability Assessment, DSHS Unpaid Intern / Volunteer Application, Indian Heritage Questionnaire (Developmental Disabilities Administration), Tell Us How We are Doing! 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(Division of Child Support), Participants Feedback (Domestic Violence Intervention Treatment), Survivors Feedback (Domestic Violence Intervention Treatment), DSHS Community Services Survey (Community Services Division, Economic Services Administration), Notice of Action Exception to Rule (Excluding AFH), Adult Residential Care Services Notice of a Change, Rule Change Comments (Residential Care Services), Code of Ethics and Standards of Practice (Division of Vocational Rehabilitation), Federal Subminimum Wage Certificate Holder, Medicaid Transformation Demonstration Notice of Action Exception to Rule, Notice of Action Exception to Rule for AFH Daily Rates, Level 4 Questionnaire for Supervisors Applying to Facilitate Level 4 Domestic Violence Intervention Treatment, Risk, Needs, and Responsivity for Assessments and Treatment Planning (Domestic Violence Intervention Treatment), Change of Address for an Existing DVIT Certification (Domestic Violence Intervention Treatment), Add, Change, or Remove Direct Service Staff for a Certified DVIT Program (Domestic Violence Intervention Treatment), Add or Remove a Service for an Existing DVIT Certification (Domestic Violence Intervention Treatment), Self-Assessment and Monitoring Tool (Home and Community Services), Community Instructor Self-Assessment (Home and Community Services), Community Instructor Self-Assessment for Contract Renewal and/or for Newly Established Contracts (Home and Community Services), Case Manager Instructions Following a Hearing Decision, Private Duty Nursing (PDN) Pre-Contract Education Attestation (Home and Community Services), Residential Referral Transition (Developmental Disabilities Administration), Nursing Assistant Training and Testing Reimbursement, Cost of Care Adjustment (COCA) (Developmental Disabilities), Residential Allowance Request / Insufficient Income and Housemate Allowance (Developmental Disabilities Administration), Residential Allowance Request / Start Up Costs (Developmental Disabilities Administration), Residential Allowance Request / Damage (Developmental Disabilities Administration), Psychologist and Sex Offender Treatment Provider Invoice, Specialized Evaluation and Treatment Provider Invoice, Division of Vocational Rehabilitation (DVR) Referral to Office of Financial Recovery Referral, AFH Change in Licensed Bed Capacity - Increase (Adult Family Home) (Residential Care Services), AFH Change in Licensed Bed Capacity - Decrease (Adult Family Home) (Residential Care Services), Individual Provider (IP) Travel Time Request, Adult Living Facility (ALF) Change in Licensed Resident Bed Capacity or Use of Rooms, Residential Training Roster / Reimbursement (Developmental Disabilities Administration), Nursing Services Activity Report for Home and Community Services (HCS), Nursing Services Activity Report for AAAs, Public Records Customer Experience Survey, Adult Family Home (AFH) Capacity Increase Working Papers (Residential Care Services), Individual Provider Planned Action Notice Training / Certification (Home and Community Services), Self Employment Monthly Sales and Expense Worksheet, Basic Food Employment and Training (BFET) Participant Reimbursement, Participant Reimbursement with Interpreter Declaration, Financial Communication to Social Services, Exception to Rule and Notice Guardianship Fees and Related Costs (Aging and Long-Term Support Administration and Developmental Disabilities Administration), Voluntary Placement Agreement for Child or Youth with Developmental Disabilities, Vendor Affidavit of Lost, Stolen, or Destroyed Warrant, Petition for Modification - Administrative Order, Authorization for Expenditure (Non-Employee), Washington State Addendum to Box 2 of Part B - Plan Administrator Response, WorkFirst Word Experience (WEX) Agreement, Confidentiality Statement - Tribal Employee, Companion Home Certification Evaluation (Developmental Disabilities Administration), Service Verification / Attendance Record For Alternative Living Providers (Developmental Disabilities Administration), Nurse Delegation: Nursing Assistant Credentials and Training, Adult Family Home (AFH) Placement Checklist (DDA), Provider Referral Letter For Residential Services (Developmental Disabilities Administration), Individual with Challenging Support Issues (DDA), Individual with Complex Behaviors (Aging and Long-Term Support Administration), Nursing Home Transfer or Discharge Notice (Residential Care Services), Request for an Administrative Hearing (Residential Care Services), Shared Parenting Plan (Developmental Disabilities), Public Health Nurse (PHN) Summary and Recommendations, Individual With Possible Community Protection Issues (Developmental Disabilities Administration), Pre-Placement Agreement (Developmental Disabilities Administration), Alternative Living Services Plan and Provider Progress Report (Developmental Disabilities Administration), Alternative Living Services Plan and Provider Progress Report Supplement to DSHS form 10-269 (Developmental Disabilities Administration), Assisted Living Facility Admission Agreement(s) Attestation, WTRS Consumer Response (Office of Deaf and Hard of Hearing), Request for Children's Residential Services, Notification of Eligibility Review (Developmental Disabilities Administration), Staffed Residential Rate Proposal (Developmental Disabilities Administration), DDA Mortality Review Provider Report (Developmental Disabilities Administration), Monitoring of Side Effects Scale (MOSES) (DDA), Important Information for SSP Recipients and Their Payees (DDA), Nursing Care Consultant (NCC) Assessment (DDA), Community Protection Program Information Checklist and Risk Assessment Consent (Developmental Disabilities Administration), Disclosure of Services Required by RCW 18.20.300, Documentation Request for Medical Condition and Residual Functional Capacity, Assisted Living Facility Pre Inspection Preparation - Attachment A, Boarding Home Request for Documentation - Assisted Living Facility Request For Documentation - Attachment B, Assisted Living Facility Resident List - Attachment C, Assisted Living Facility Resident Characteristic Roster and Sample Selection - Attachment D, Assisted Living Facility Resident Group Meeting - Attachment E, Assisted Living Facility Resident Interview - Attachment G, Assisted Living Facility Other Contact Interview - Attachment H, Assisted Living Facility Environmental Observations - Attachment I, Assisted Living Facility Resident Record Review - Attachment J, Assisted Living Facility Staff Sample / Record Review - Attachment K, Assisted Living Facility Notes / Worksheet - Attachment L, Assisted Living Facility Exit Preparation Worksheet - Attachment M, Assisted Living Facility Contract Requirements - Attachment N, Assisted Living Facility Environmental Observations for Contract Requirements - Attachment O, Notification of Age Four (4) Eligibility Expiration-, Notification of Age Ten (10) Eligibility Expiration, Room List For Assisted Living Facilities (ALF), Additional Room List For Assisted Living Facilities (ALF), Cost Estimate Worksheet for Hearing Aids and Services, Residential Services Provider: Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult, Consumer Response: Do Not Hang Up Complaint, Adult Family Home License Relinquishment Letter, Application For Contract For Currently Licensed Assisted Living Facility, Adult Family Home Caregiver Experience Attestation (CEA), Adult Family Home (AFH) Quality Improvement Initial Visit, Shared Planning for Youth Aged 18-21 Receiving Voluntary Placement Services, Voluntary Participation Statement (Developmental Disability Administration), Temporary Manager and/or Receiver Application Nursing Home and Assisted Living Facility, Long-Term Care Partnership (LTCP) Asset Designation, Goal Setting and Action Planning Worksheet, Nurse Delegation Contract Monitoring Chart Audit, ALTSA Sentence / Copy Design Folstein MMSE (Home and Community Services), HCS / AAA / ODHH / DDA Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults, Child and Family Team (CFT) Care Plan (Developmental Disabilities Administration), Quality Review Tool: Functional Assessment / Positive Behavior Support Plan (Developmental Disabilities Administration), Assisted Living Facility Food Service Observations - Attachment P, Assisted Living Facility Medication Pass Worksheet - Attachment Q, Confidential Health Information Consent Agreement, Referral to DSHS for Basic Food Employment and Training (BFET), Limitation Extension Request for Clients Under Age 21, Adult Family Home Disclosure of Services Required by RCW 70.128.280, Overnight Planned Respite Services Individualized Agreement, Respite Application for Overnight Planned Respite (OPRS), Emergent and/or Planned Short-Term Stay Services at an RHC, Planned Action Notice - Pre-Admission Screening and Resident Review (PASRR) Determination, Roads to Community Living (RCL) Person Centered Transition Planning, Assisted Living Facility Other Contact Information - Attachment R, Notification of Age 19 Eligibility Review (Developmental Disabilities Administration), Data Summary Report and Recommendations (Developmental Disabilities Administration), Comprehensive Functional Assessment of Recreation, Comprehensive Functional Assessment of Physical Therapy, Assisted Living Facility License Application, Comprehensive Functional Assessment of Direct Care Independent Living Skills, Restraint / Support Evaluation Continuation, Comprehensive Functional Assessment of Communication, Comprehensive Functional Assessment of Occupational Therapy, Comprehensive Functional Assessment of Adult Training Programs, Assisted Living Facility Information Changes, Enhanced Services Facility Information Changes, Supported Living Information Changes (Residential Care Services), ICF / IID Information Changes (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Face Sheet (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Pre-Certification Evaluation Preparation (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Observation(Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Client Interview (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Family / Representative / Collateral Contact Interview (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Interview (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Home Environment and Safety Worksheet (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Certification Evaluation Staff Sample / Record Review (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Background Check Record Review (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Residential Cost Report – ISS Hours Review / Questionnaire (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Notes (Residential Care Services), Certified Community Residential Services and Supports (CCRSS) Group Training Home Food Service Observations and Interviews (Residential Care Services), DDA PASRR Significant Change Invalidation (Developmental Disabilities Administration) (Pre-Admission Screening and Resident Review), State Task Checklist (Aging and Long-Term Support Administration), Staffing Pattern (Aging and Long-Term Support Administration), Liability Insurance Review (Aging and Long-Term Support Administration), Trust Fund Review (Aging and Long-Term Support Administration), Pet Record Review (Aging and Long-Term Support Administration), Paid Feeding Assistant Program Review (Aging and Long-Term Support Administration), Staff Qualification and Background Review (Aging and Long-Term Support Administration), TB Testing Review for Staff (Aging and Long-Term Support Administration), TB Testing Review for Resident (Aging and Long-Term Support Administration), Medication Assistant Endorsement (Aging and Long-Term Support Administration), Residential Transition Exchange of Information (Developmental Disabilities Administration), AFH Meaningful Day - Monthly Activities and Challenging Behavior Log, Overnight Planned Respite Services (OPRS) Certification Evaluation (Developmental Disabilities Administration), Emphasis on Hands-On Skills Practice: Planning Attestation (Home and Community Services), Community Instructor Qualification Tool (Home and Community Services), Components of Your 75 Hour Home Care Aide Training Program (Home and Community Services), PASRR Request for Skilled Nursing in a Community Setting (Pre-admission Screening and Resident Review) (Developmental Disabilities Administration), Home and Community-Based Services (HCBS) Waiver Approval Notification (DDA), Residential Certification Evaluation Client Interview (Developmental Disabilities Administration), Residential Certification Evaluation Legal Representative Interview (Developmental Disabilities Administration), Residential Certification Evaluation Staff Interview (Developmental Disabilities Administration), Planned Action Notice PASRR Determination Supporting Information (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration), Children's State Operated Living Alternatives (SOLA) Review and Evaluation (Developmental Disabilities Administration), Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services), Adult Family Home (AFH) Private Duty Nursing (PDN) Contract Monitoring Tool (Home and Community Services), State Civil Penalty Reinvestment Program Grant (SCPRP) Community Residential Services and Supports (CCRSS) Grant Application, Initial Staff and Family Consultation Plan (Developmental Disabilities Administration), Staff and Family Consultation (SFC) 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration), Initial Specialized Habilitation Plan (Developmental Disabilities Administration), Specialized Habilitation 90-Day (Quarterly) Report (Developmental Disabilities Administration), Initial Community Engagement Plan (Developmental Disabilities Administration), Community Engagement 90-Day (Quarterly) Progress Report (Developmental Disabilities Administration), Music Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration), Equine Therapy 90-Day (Quarterly) Report (Developmental Disabilities Administration), Existing Companion Home (CH) Movers Checklist (Developmental Disabilities Administration), New or Update Provider Information Worksheet (Developmental Disabilities Administration), Vocational Information (Division of Vocational Rehabilitation), Application for Vocational Rehabilitation Services, Service Delivery Outcome Report (Community Rehabilitation Program - CRP), Basic Food Eligibility Requirements: What You Need to Know, Work Experience (WEX) Referral (Food Stamp Employment and Training), Work Experience (WEX) Agreement (Food Stamp Employment and Training), Acknowledgement of My Responsibilities As The Employer of My Individual Providers, Acknowledgement of My Responsibilities as the Employer of My Individual Providers - Temporary COVID Pandemic Version, Trial Work Experience (TWE) Agreement (Division of Vocational Rehabilitation), Assistive Communication Technology Request (Office of Deaf and Hard of Hearing), Monthly Budget Worksheet (Division of Vocational Rehabilitation), DVR Internship Application (Division of Vocational Rehabilitation), DVR Internship Agreement (Division of Vocational Rehabilitation), DVR Attendance Log and Billing Invoice (Division of Vocational Rehabilitation), DVR Employer Expense Worksheet (Division of Vocational Rehabilitation), DVR Internship Evaluation (Division of Vocational Rehabilitation), Centers for Independent Living (CILs), Title VII, Part B Two-Year Plan (Division of Vocational Rehabilitation), Centers for Independent Living (CILs) Title VII, Part B, Contract Annual Report, Centers for Independent Living (CILs) Title VII, Part B Monthly Report, Contracted Employee(s) to Provide IL Services and Service(s) Approved (Division of Vocational Rehabilitation), DVR, DSB, and PIHE Student Accommodation Cost Share Worksheet, Outreach Attendance (Office of the Deaf and Hard of Hearing), Service Delivery Outcome Report (Independent Living Services - IL), Community Rehabilitation Program (CRP) Generic Update Report, Pre-ETS (Pre-Employment Transition Services) Self-Advocacy Training (Division of Vocational Rehabilitation), Pre-ETS (Pre-Employment Transition Services) Peer Mentoring (Division of Vocational Rehabilitation), Pre-ETS (Pre-Employment Transition Services) Informational Interview (Division of Vocational Rehabilitation), Pre-ETS (Pre-Employment Transition Services) Job Shadow (Division of Vocational Rehabilitation), Individualized Plan for Employment (IPE) Worksheet (Division of Vocational Rehabilitation), Informational Interview Worksheet (Division of Vocational Rehabilitation), Enhanced Case Management Referral Consideration (Developmental Disabilities Administration), Service Delivery Outcome Plan: WBL - Experience A, Service Delivery Outcome Plan: WBL - Experience B, Service Delivery Outcome Plan: WBL - Experience C, 90 Day Review (Division of Vocational Rehabilitation), Jobs and Training Inventory (Division of Vocational Rehabilitation), Deaf - Blind Referral Criteria Checklist for Level 4 Community Rehabilitation Program (CRP) Services (Division of Vocational Rehabilitation), Service Delivery Outcome Plan: Pre-ETS IL Skills Training, Supported Employment Referral (Economic Services Administration), Division of Vocational Rehabilitation (DVR) Customer Job Seeker Accommodation Worksheet, Basis of Issuance Tables and Maximum Allowable Monthly Gross and Net Income Standards for the Washington Basic Food Program, Waiver of Administrative Disqualification Hearing (Community Services Division), Adult Family Home Injuries and Accidents Log, Nurse Delegation: Consent for Delegation Process, Nurse Delegation: Instructions for Nursing Task, Nurse Delegation: Assumption of Delegation, Nurse Delegation: Change in Medical Orders, Assisted Living Facility (ALF) Dementia Screening Tool, Behavioral Health Personal Care (BHPC) Request for MCO Funding (Aging and Long-Term Support Administration), Documentation of First Use of Medicaid Benefits (DDA), HCS / AAA Nursing Services Referral (Home and Community Services), Nursing Services Basic Skin Assessment (Home and Community Services), Pressure Injury Assessment and Documentation (Home and Community Services), Admissions Review Team Checklist for Admission to an ICF / IID or SONF at a Residential Habilitation Center (RHC) (Developmental Disabilities Administration), Psychoactive Medication Treatment Plan Annual Continuation of Medication, Nurse Delegation: Request For Additional Units, DDA Request for Additional Units Nurse Delegation (Developmental Disability Administration), Autistic Disorder Confirmation (Developmental Disabilities Administration), Therapy Assessment Bed Rails or Side Rails (Home and Community Services), DDA Nursing Service Referral (Developmental Disabilities Administration), CCSS Medical / Dental Services Authorization (Community Crisis Stabilization Services) (Developmental Disabilities Administration), Weekly Status Update (Competency Restoration Program) (Behavioral Rehabilitation Administration), Outpatient Competency Restoration Program (OCRP) Discharge Summary, Request for Formulary Admission or Deletion (Behavioral Health Administration), Non-Formulary Drug Use Request (Behavioral Health Administration), Non-Formulary Drug Use Request: Risperidone Consta, Aripiprazole Maintena, Paliperidone Sustenna (Behavioral Health Administration), Forensic (6358) Consultation (Behavioral Health Administration), Involuntary Antipsychotic Medication Hearing Checklist (Behavioral Health Administration), Statement of Health, Education, and Employment, Noncustodial Parent Child Support Enforcement Application, Financial Statement (Division of Vocational Rehabilitation), Interview Appointment for Applicant (Community Services Division), Your Cash and Food Assistance Rights and Responsibilities, Request for DDA Eligibility Determination, Statement of Collateral Information Summary, Application for Telecommunications Equipment, Adult Assessment Referral (Economic Services Administration), Level One Pre-Admission Screening and Resident Review (PASRR), Application to Convert Payment Services Only (PSO) Case to Full Collection Services, Notification of Address Disclosure Request - Part 1, Notification of Address Disclosure Request - Part 2, Eligibility Review for Long Term Services and Supports, Protective Payee Payment Plan, Case Assignment, and Closure Notice, Medical / Dental Services Authorization (Voluntary Placement Services) (Developmental Disabilities Administration), Community Crisis Stabilization Services (CCSS) Medical / Dental Services Authorization (Developmental Disabilities Administration), Statement of Adult Acting in Loco Parentis (As a Parent), Washington State Combined Application Program (WASHCAP) Application, Non-Profit Organization Application for Reconditioned Telecommunications Equipment (Office of the Deaf and Hard of Hearing), Financial / Social Services Communication, Estate Recovery: Repaying the State for Medical and Long Term Services and Supports, Eligible Conditions With Age and Type of Evidence (Developmental Disabilities Administration), Notice of Insufficient Information (Developmental Disabilities Administration), Epilepsy Verification Request (Developmental Disabilities Administration), Inventory for Client and Agency Planning (ICAP) Letter, Appointment Letter for Division of Child Support (DCS) Good Cause Determination, NSA Representative Checklist forDDA Review, Requirement to Identify a Representative (Developmental Disabilities Administration), Interim Assistance Reimbursement Agreement Cover, Your Responsibility to Pay Towards Costs of Care at the Residential Habilitation Center, Your DSHS Cash or Food Assistance Benefits, Your Rights (Home and Community Services), Incapacity Review for Medical Care Services, Chemical Dependency Treatment Verification Request, Substance Use Disorder Requirements (HEN Referral Program), Substance Use Disorder Requirements (ABD / PWA), SDCP Eligibility Checklist (Home and Community Services), Notice of Insufficient Information for Reapplication (Developmental Disabilities Administration), Pre-Admission Screening and Resident Review (PASRR) Addendum, ABAWD Requirement: Medical Report (Able Bodied Adults without Dependents), Application for New Program Certification (Domestic Violence Intervention Treatment), Application for Renewal Program Certification (Domestic Violence Intervention Treatment), Continuing Education Summary for DVPT Providers (Domestic Violence Intervention Treatment), Continuing Care Retirement Community (CCRC) Registration Application, Job Foundation Application (Developmental Disabilities Administration), Adult Family Homes (AFH) State Civil Penalty Reinvestment Program Grant Application, Request for Enrollment in Developmental Disabilities Administration (DDA) Home and Community Based Services (HCBS) Waiver or Request to Change from One DDA HCBS Waiver to Another, Notification of Annual Assessment Review and Person Centered Services Planning Meeting, Person Centered Service Planning and Annual Assessment Meeting, Person Centered Service Plan Meeting Survey (Developmental Disabilities Administration), HCBS Waiver Enrollment Database Update (Developmental Disabilities Administration), Client Necessary Supplemental Accommodation Representative Requirement Checklist, DDA Crisis Diversion Bed Referral and Intake Information, Annual Assessment Checklist (Developmental Disability Administration), Private Duty Nursing Logs and Skilled Nursing Tasks Log, DDA Community Protection Program Chaperone Agreement, Client Referral Summary (Developmental Disabilities Administration), Community Protection Treatment Worksheet Quarterly Review, Staff Add-on Request for Client Specific Need (Developmental Disabilities Administration)), Individual and Family Services Assessment Worksheet (Developmental Disabilities Administration), Provider Progress Report of Behavior Management and Consultation and Staff/Family Training and Consultation Services (DDA), Provider Consent For Use of Restrictive Procedures Requiring an ETP, Alternative Living Certification Evaluation (Developmental Disabilities Administration), Certified Community Residential Services and Support Initial Application, Medically Intensive Children's Program (MICP) Application, Staffed Residential Cost of Care Adjustment Request, Documentation of Early Support for Infants and Toddlers (ESIT) for Developmental Disabilities Administration, Request for Adult Family Home Application Fee Waiver, Resident Choice Regarding Assisted Living Facility (ALF) Room Requirements (Home and Community Services), Adult Family Home Disclosure of Charges Required by RCW 70.128.280, RCS Character, Competence and Suitability (CSS) Determination for Unsupervised Access to Minors and Vulnerable Adults, Adult Family Home Notice of Transfer or Change, Notification of Age 18 Eligibility Expiration, Notification of Age 20 Eligibility Expiration, Notification Regarding Request to Exceed Work Week Limit (Home and Community Services) - TRANSLATIONS ONLY, Medicaid Transformation Demonstration Service Notice, Guardian / Family Response to Individual Habilitation Plan (IHP) Notification (Developmental Disabilities Administration), Individual Habilitation Plan (IHP) (Developmental Disabilities Administration), Individual Habilitation Plan (IHP) Revision (Developmental Disabilities Administration), Notification of Initial Assessment Request (Developmental Disabilities Administration), Consent and Service Agreement (Developmental Disabilities Administration), Provider Progress Report of Community Guide and Engagement Services (Developmental Disabilities Administration)), Companion Home and Alternative Living Services Incident Report (Developmental Disabilities Administration), Companion Home (CH) Client Individual Financial Plan (IFP) (Developmental Disabilities Administration), CCSS Family Agreement (Community Crisis Stabilization Services) (Developmental Disabilities Administration), Companion Home Quarterly Report (Developmental Disabilities Administration), Application for Transition from Group Home to Group Training Home, Continuing Education Event Approval Application (Aging and Long-Term Support Administration), Adult Family Home Administrator Training Instructor Application (Home and Community Services), Community Instructor Application: DSHS Adult Education (Home and Community Services), Community Instructor Application (Home and Community Services), Community Instructor Training Program Application and Updates (Home and Community Services), Curriculum Approval Application (Home and Community Services), Long-Term Care Worker Basic Training Enhancement Instructions and Application (Home and Community Services), Facility Instructor Application (Home and Community Services), Facility Training Program Application and Updates (Home and Community Services), Continuing Care Retirement Community (CCRC) Registration Renewal Addendum (Aging and Long-Term Support Administration), Adult Family Home (AFH) Resident Significant Change Assessment Request, Adult Family Home Referral Request (Developmental Disabilities Administration), Room Requirements Checklist (Home and Community Services), Residential Quarterly Report for Children's Residential Services (Developmental Disabilities Administration), Nursing Home (NH) Complaint Investigation (CI) Skill Building Tool, On-the-Job Facility Training Plan Application and Updates (Home and Community Services), DDA Alternative Living Provider Orientation (Developmental Disabilities Administration), Notice of Termination of Service (Developmental Disabilities Administration), Enhanced Services Facility (ESF) Pre-Inspection Preparation, Enhanced Services Facility (ESF) Request for Documentation, Enhanced Services Facility (ESF) Resident List, Enhanced Services Facility (ESF) Resident Characteristic Roster and Sample Selection, Enhanced Services Facility (ESF) Resident Interview, Enhanced Services Facility (ESF) Other Contact Inverview, ced Services Facility (ESF) Environmental Observations, Enhanced Services Facility (ESF) Resident Record Review, Enhanced Services Facility (ESF) Staff and Administrative Record Review, Enhanced Services Facility (ESF) Training Requirements, Enhanced Services Facility (ESF) Notes / Worksheets, Enhanced Services Facility (ESF) Exit Preparation Worksheet, Enhanced Services Facility (ESF) Food Service Observations and Interviews, Enhanced Services Facility (ESF) Medication Pass Worksheet, Enhanced Services Facility (ESF) Staff Schedule Worksheet, Enhanced Services Facility (ESF) Pre-Inspection Packet, NonAssistance Support Enforcement Information (Division of Child Support), Noncustodial Parent's Rights and Responsibilities, Your Rights and Responsibilities When You Receive Services Offered by Aging and Disability Services Administration and Developmental Disabilities Administration, Guidelines for Completing the ICAP / SIB-R Adaptive Behavior Scale (Developmental Disabilities Administration), SOLA Vehicle Trip Log (Developmental Disabilities Administration), Information About Your Role as the Identified Necessary Supplemental Accommodation (NSA) Representative, Assisted Living Facility Policies and Procedures Attestation, Individual Provider Notification: Stop Work Notice, New Case/Resource Manager Technology Training Checklist, Memo to Provider for Behavior Support, Counseling, and Consultation Services, New Case / Resource Manager Assessment (Developmental Disabilities Administration), 5-Day Investigation Report (Developmental Disabilities Administration (DDA), Corrective Action Plan (5-Day Investigation) (Developmental Disabilities Administration), SIS-A Rating Key (Developmental Disabilities Administration), Vulnerable Adult Statement of Rights (Intended for use in NH, ALF, AFH, ICF/IID (non RHC) and ESF), Vulnerable Adult Statement of Rights (Intended for use in CCRSS and ICF/IID (RHC)), DDA GovDelivery Communication Request (Developmental Disabilities Administration), Community Services Office (CSO) Compliments and Concerns (Economic Services Administration), New Freedom Participant Responsibility Agreement, Skills Practice Procedure Checklist for Home Care Aides DSHS Approved (Home and Community Services), Your rights as a client of the Developmental Disabilities Administration, AIS TRACKS Fixed Asset Inventory Local Office Certificate of Completion, Spoken Language Interpreter Service Appointment Record, Personal Information Release (Economic Services Administration), Request for Mental Health Service Information, PRISM Access Request for Multiple Organizations, Authorization for SSI Facilitation Records (Economic Services Administration), AAA DSHS / HCS Systems Access Request (Aging and Long-Term Support Administration), Pre-Admission Screening and Resident Review (PASRR) Records Request, Non-Emergency Medical Transportation (NEMT) for PASRR Program Request, Mental Incapacity Evaluation (MIE) Contractor Travel Plan, ODHH Approved Sign Language Interpreter Complaints, Residential Habilitation Center (RHC) Informed Consent (Developmental Disabilities Administration), DSHS Background Check System (BCS) Access Request, Companion Home Client Budget Worksheet (Developmental Disabilities Administration), Companion Home Client Cash Ledger (Developmental Disabilities Administration), Companion Home Gift Card or Pre-paid Credit Card Ledger (Developmental Disabilities Administration), Assistive Communication Technology (ACT) Contractor Assignment Report (Office of Deaf and Hard of Hearing), Companion Home Physical and Safety Requirements Review (Developmental Disabilities Administration), Background Check Review: Character, Competence, and Suitability for Contractor Employees / Volunteers (Division of Vocational Rehabilitation), DVR Background Check Reporting (Division of Vocational Rehabilitation), DSHS / DVR Request for Approval to Subcontract Checklist (Division of Vocational Rehabilitation), Contractor Designated Contact(s) Background Check (Division of Vocational Rehabilitation), PASRR Equipment Purchase Request (Pre-Admission Screening and Resident Review) (Developmental Disabilities Administration), Qualified Sign Language Interpreter Request (Office of Deaf and Hard of Hearing), Assistive Communication Technology (ACT) Program Service Request / Work Order for Induction Loops (Office of the Deaf and Hard of Hearing), Outpatient Competency Restoration Program Clinical Screening (Behavioral Health Administration), Residential Quality Assurance Certification Evaluation Checklist for Companion Homes Providers (Developmental Disabilities Administration), Residential Quality Assurance Certification Evaluation Checklist for Alternative Living Providers (Developmental Disabilities Administration), Removal and Transport Directive (Behavioral Health Administration), Vendor Agreement Information (Behavioral Health Administration), BHA Personal Information Release (Behavioral Health Administration), Medical Expense Examples (Community Services Division, Economic Services Administration), Application for Nonassistance Support Enforcement Services, Initial payment (Interim Assistance Reimbursement Authorization), How You Must Help with Child Support Collection for Temporary Assistance for Needy Families (TANF) and Medical Assistance Programs, Social Service Incorrect Payment Computation, Non-SSPS Client / Provider Overpayment AFRS Coding Computation, Declaration of Support Payments (Division of Child Support), New Hire Reporting Methods and Instructions (Division of Child Support), New Hire Reporting Methods and Instructions, Employer Payment Identification Instructions, Automatic Payment Authorization and Electronic Funds Transfer Information, SSP Client Overpayment Notice (State Supplementary Program), Request for Collection of Uninsured Health Care Expenses, Detail Sheet – Uninsured Health Care Expenses, Request for Income Information for Purposes of Entering or Enforcing a Child Support Order, Loan Agreement for Tools, Equipment, Initial Stock and Supplies, and Devices (Division of Vocational Rehabilitation), Application Budget Summary (Residential Care Services), Family Agreement to Children's Intensive In-home Behavioral Support (CIIBS) Program, Incident Report to DDA (Developmental Disabilities Administration), Appropriate Level of Forensic Services (ALFS) Screening Tool, Outpatient Competency Restoration Program (OCRP) Transition Plan (Behavioral Health Administration), Children's Staffed Residential Quality Assurance Assessment, Children’s State Operated Living Alternative (SOLA) Quality Assurance Assessment, Companion Home Monthly Emergency Evacuation Practice and Water Temperature Record (Developmental Disabilities Administration), Alternative Living Monthly Financial Report, Community Services Division (CSD) Financial Confidence Wheel (Economic Services Division), Contractor Information Update (for existing DSHS contractors), Voluntary Placement Services Provider Referral Letter (DDA), Voluntary Placement Services For Youth (Age 18-21), Mandatory Reporting of Abuse, Neglect, Personal and Financial Exploitation, or Abandonment of a Child or Vulnerable Adult, Employment and Day Program Services Providers: Mandatory Reporting of Abuse, Improper Use of Restraint, Neglect, Personal or Financial Exploitation, Abandonment of a Child or Vulnerable Adult (Developmental Disability Administration), Fingerprint-Based Background Check Notice, Medicaid Provider Disclosure Statement (Aging and Long-Term Support Administration), Permission to Share Documents for Reimbursement of Health Care Expenses, Applicant Request for a Copy of Background Check Information, HCS / AAA / DDA Individual Provider Contractor Intake, Provider Owned Housing Memorandum of Understanding Renter Attestation, Provider Owned Housing Memorandum of Understanding Residential Provider Attestation, Authorization for Alternate EBT Cardholder, CSD ABD Medical Evidence Review Contractor Self-Assessment Monitoring Tool, CSD Disability Eligibility Review Contractor Self-Assessment Monitoring Tool, Housing Modification Property Release Agreement, Notice and Consent of Communication via Text, DVR Additional Contractor Information (Division of Vocational Rehabilitation), Release of Liability (Developmental Disabilities Administration), Adult Protective Services (APS) Administrative Hearing Request, Adult Family Home (AFH) Informal Dispute Resolution (IDR) Request (Residential Care Services), DSHS Request for Positive Identification – Thumbprint, Initial Opiate Prescription Informed Consent (Behavioral Health Administration), Asset Verification Authorization (Home and Community Services), Home and Community Services (HCS) Resumption of Training Attestation, Complimentary Therapies Agreement (Developmental Disabilities Administration). 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