​​This page includes ​commonly requested forms for nursing facilities. 

  • If you don't see the form you're looking for, try our Forms and Publication search page.
  • If you have a disability and need a document in an alternate format, you can ​send an email or call the Forms and Publications office at 503-378-3486 or TTY 503-378-3523. If you know of others who need this accommodation, please let them know it is available.​

Forms list​

  
APD 0467 - Waiver Request Form
APD 2803 - Nursing Facility Reported Incident (FRI) Form (PDF)
APD 2803 - Nursing Facility Reported Incident (FRI) Form (Word)
DHS 0035 - Nursing Facility Financial Statement, Nursing Facilities (Excel)
DHS 0035A - Nursing Facility Financial Statement (Excel)
DHS 0035A Nursing Facility Revenue Report (Excel)
DHS 9028 – Do You Have a Complaint? – This poster can be ordered through Forms. (PDF)
DHS 9847 - Leaving the Nursing Facility (brochure) (PDF)
Enhanced Wage Add-on Program Attestation Form
Form SE0466d Owner & Controlling Interest
Long-Term Care Capital Improvement and Emergency Preparedness Authorization Form
QED 301 - Criminal Background Check Authorization
SDS 0462 - Nursing Facility Residents Change in Status (Word)
SDS 0509 - Nursing Facility Notice of Transfer (Word)
SDS 0510 - Notice of Denial of Re-admission/Return (Word)
SDS 0717 - Direct Care Staff Daily Report (PDF)
SDS 0717 – Direct Care Staff Daily Report (Word)
SDS 0717A - Nursing Assistant (NA) Staff Ratio Chart (PDF)
SDS 0717A - Nursing Assistant (NA) Staff Ratio Chart (Word)
SDS 0825 – Petition for Reconsideration (PDF)
SDS 0940 – Memory Care Community Endorsement Application and Instructions (Word)
SDS 9098 MC - The Uniform Disclosure Statement for Memory Care Communities (Word)
SDS Form 0466C Licensing Credit Check
SDS Form 0466D Ownership
SDS Form 940 Memory Care Endorsement
SDS O825 – Petition for Reconsideration (Word)
SE0451B - Nursing Assistant Training and Competency Evaluation Program (Word)

​​​​​​