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Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org

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Last Updated:  11/19/2009
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OKDHS Home > Library > Forms > Forms and Applications for Services
Library: Forms
OKDHS Forms
To view these forms, please choose the associated icon under the View column. In order to view the forms correctly, site guests may need additional software. In some cases, forms are saved as .pdf or .doc files. To take full advantage of the OKDHS content, get the latest versions of Adobe Acrobat Reader or Microsoft Word Viewer from the Downloads and Plug-ins page.
Formas
307 forms found    Page 1  2  3  4  5  6  7   
View Form No.Results shown in ascending orderLegacy No.Form Name Category
Open Request for Title XIX Nursing Assessment (.doc, 2 pp, 1132 KB)Open Request for Title XIX Nursing Assessment (.pdf, 2 pp, 151 KB)
02AG001E
ABCDM-083-ARequest for Title XIX Nursing AssessmentAging  
Medical  
Open Older Americans Act Assessment, Part I (.doc, 5 pp, 1.3 MB)Open Older Americans Act Assessment, Part I (.pdf, 5 pp, 243 KB)
02AG002E
AG-002-A, PART IOlder Americans Act Assessment, Part IAging  
Open Older Americans Act Assessment, Part II (.doc, 2 pp, 593 KB)Open Older Americans Act Assessment, Part II (.pdf, 2 pp, 75 KB)
02AG003E
AG-002-A, PART IIOlder Americans Act Assessment, Part IIAging  
Open Change of Client Status (.doc, 2 pp, 575 KB)Open Change of Client Status (.pdf, 2 pp, 166 KB)Open Change of Client Status Instructions (.pdf, 1 pp, 15 KB)
02AG004E
AG-002-BChange of Client StatusAging  
Open Annual Assessment (.doc, 10 pp, 584 KB)Open Annual Assessment (.pdf, 10 pp, 202 KB)
02AG005E
AG-025Annual AssessmentAging  
Open Voluntary Withdrawal of Title III Project (.doc, 1 pp, 668 KB)Open Voluntary Withdrawal of Title III Project (.pdf, 1 pp, 128 KB)
02AG006E
AG-029Voluntary Withdrawal of Title III ProjectAging  
Open Equipment Inventory (.doc, 2 pp, 518 KB)
02AG013E
SUOA-S-016Equipment InventoryAging  
Open In-Kind Travel Expense Voucher (.doc, 1 pp, 1336 KB)Open In-Kind Travel Expense Voucher (.pdf, 1 pp, 201 KB)
02AG014E
SUOA-S-017In-Kind Travel Expense VoucherAging  
Open Nutrition Project Attendance Form (.doc, 2 pp, 757 KB)Open Nutrition Project Attendance Form (.pdf, 2 pp, 183 KB)
02AG016E
SUOA-S-032Nutrition Project Attendance FormAging  
Open Individual Attendance Record (.doc, 2 pp, 269 KB)
02AG017E
SUOA-S-033Individual Attendance RecordAging  
Open Project Menu Plan - Nutrition Program for the Elderly (.doc, 1 pp, 988 KB)Open Project Menu Plan - Nutrition Program for the Elderly (.pdf, 1 pp, 154 KB)
02AG018E
SUOA-S-034Project Menu Plan - Nutrition Program for the ElderlyAging  
Open Number of Meals Served (.doc, 2 pp, 985 KB)Open Number of Meals Served (.pdf, 2 pp, 1.7 MB)Open Number of Meals Served Instructions (.pdf, 2 pp, 22 KB)
02AG019E
SUOA-S-038Number of Meals ServedAging  
Open Area Agency on Aging (AAA) Quarterly Report (.doc, 3 pp, 1.1 MB)Open Area Agency on Aging (AAA) Quarterly Report (.pdf, 2 pp, 160 KB)
02AG020E
SUOA-S-054Area Agency on Aging (AAA) Quarterly ReportAging  
Open Area Agency on Aging (AAA) Quarterly Report - A (.doc, 3 pp, 1.7 MB)Open Area Agency on Aging (AAA) Quarterly Report - A (.pdf, 3 pp, 472 KB)
02AG021E
SUOA-S-54-AArea Agency on Aging (AAA) Quarterly Report - AAging  
Open Cumulative Program Performance Report (.doc, 1 pp, 765 KB)Open Cumulative Program Performance Report (.pdf, 1 pp, 218 KB)Open Cumulative Program Performance Report Instructions (.pdf, 1 pp, 31 KB)
02AG022E
SUOA-S-056-ACumulative Program Performance ReportAging  
Open Service Expenditures Profile (.doc, 2 pp, 721 KB)Open Service Expenditures Profile (.pdf, 2 pp, 336 KB)Open Service Expenditures Profile Instructions (.pdf, 1 pp, 22 KB)
02AG023E
SUOA-S-056-CService Expenditures ProfileAging  
Open Consumable Supplies Inventory (.doc, 1 pp, 624 KB)Open Consumable Supplies Inventory (.pdf, 1 pp, 165 KB)Open Consumable Supplies Inventory Instructions (.pdf, 1 pp, 30 KB)
02AG024E
SUOA-S-071Consumable Supplies InventoryAging  
Open Dietary Consultants Report (.doc, 1 pp, 574 KB)Open Dietary Consultants Report (.pdf, 1 pp, 176 KB)Open Dietary Consultants Report Instructions (.pdf, 1 pp, 19 KB)
02AG025E
SUOA-074Dietary Consultant's ReportAging  
Open Audit Report Transmittal (.doc, 1 pp, 859 KB)Open Audit Report Transmittal (.pdf, 1 pp, 230 KB)
02AG026E
SUOA-S-081Audit Report TransmittalAging  
Open Area Agency Quarterly Summary of Program Income (.doc, 1 pp, 147 KB)
02AG027E
SUOA-S-084Area Agency Quarterly Summary of Program IncomeAging  
Open Management Plan (.doc, 1 pp, 679 KB)Open Management Plan (.pdf, 1 pp, 180 KB)
02AG028E
AG-030Management PlanAging  
Open Personal Care Plan (.doc, 4 pp, 92 KB)Open Personal Care Plan Instructions (.pdf, 1 pp, 14 KB)
02AG029E
AG-004Personal Care Plan Aging  
Open Personal Care Planning Schedule (.doc, 1 pp, 1.5 MB)Open Personal Care Planning Schedule (.pdf, 4 pp, 299 KB)Open Personal Care Planning Schedule Instructions (.pdf, 1 pp, 27 KB)
02AG030E
AG-005Personal Care Planning ScheduleAging  
Open Personal Care (PC) Service Plan (.doc, 1 pp, 866 KB)Open Personal Care (PC) Service Plan (.pdf, 1 pp, 134 KB)Open Personal Care (PC) Service Plan Instructions (.pdf, 2 pp, 23 KB)
02AG031E
AG-6Personal Care (PC) Service PlanAging  
Open Personal Care Provider Communication (.doc, 1 pp, 515 KB)Open Personal Care Provider Communication (.pdf, 1 pp, 143 KB)Open Personal Care Provider Communication Instructions (.pdf, 1 pp, 15 KB)
02AG032E
AG-007Personal Care Provider CommunicationAging  
Open Personal Care Agency Referral (.doc, 1 pp, 56 KB)
02AG033E
AG-008Personal Care Agency ReferralAging  
Open Personal Care Progress Notes (.doc, 2 pp, 228 KB)Open Personal Care Progress Notes Instructions (.pdf, 1 pp, 21 KB)
02AG039E
AG-022Personal Care Progress Notes Aging  
Open Personal Care Assistant (PCA) Supervisor Visit (.doc, 2 pp, 122 KB)Open Personal Care Assistant (PCA) Supervisor Visit (.pdf, 2 pp, 234 KB)Open Personal Care Assistant (PCA) Supervisor Visit Instructions (.pdf, 1 pp, 15 KB)
02AG040E
AG-022-APersonal Care Assistant (PCA) Supervisor VisitAging  
Open Documentation of Qualifications to Provide Personal Care Services (.doc, 2 pp, 140 KB)Open Documentation of Qualifications to Provide Personal Care Services Instructions (.pdf, 1 pp, 19 KB)
02AG041E
AG-024Documentation of Qualifications to Provide Personal Care Services Aging  
Open State Plan Personal Care (SPPC) Progress Notes (.doc, 4 pp, 993 KB)Open State Plan Personal Care (SPPC) Progress Notes (.pdf, 4 pp, 355 KB)
02AG044E
N/AState Plan Personal Care (SPPC) Progress NotesAging  
Open Recruitment Incident Report (.doc, 2 pp, 674 KB)Open Recruitment Incident Report (.pdf, 2 pp, 124 KB)
02AG047E
N/ARecruitment Incident ReportAging  
Open Notice to Comply (.doc, 2 pp, 661 KB)Open Notice to Comply (.pdf, 2 pp, 120 KB)
02AG048E
N/ANotice to ComplyAging  
Open Adult Day Service Invoice (.doc, 1 pp, 82 KB)Open Adult Day Service Invoice Instructions (.pdf, 2 pp, 16 KB)
02AS001E
ADM-012-ADS-SIAdult Day Service Invoice Adult Day Services  
Aging  
Open Adult Day Services Monthly Report (.doc, 2 pp, 93 KB)Open Adult Day Services Monthly Report (.pdf, 2 pp, 196 KB)
02AS002E
ADS-MR-1Adult Day Services Monthly ReportAdult Day Services  
Open Adult Day Services Referral/Application (.doc, 3 pp, 715 KB)Open Adult Day Services Referral/Application (.pdf, 3 pp, 184 KB)Open Adult Day Services Referral/Application Instructions (.pdf, 1 pp, 13 KB)
02AS003E
ADS-RA-1Adult Day Services Referral/ApplicationAdult Day Services  
Applications  
Aging  
Open Service/Attendance/Claim Record (.doc, 1 pp, 1.0 MB)Open Service/Attendance/Claim Record Instructions (.pdf, 1 pp, 20 MB)
02AS004E
AS-ADS-001Service/Attendance/Claim Record Adult Day Services  
Aging  
Open Uniform Comprehensive Assessment (.doc. 5 pp. 1.4 MB)Open Uniform Comprehensive Assessment (.pdf, 5 pp, 363 KB)
02HM001E
AG-002, PART IUniform Comprehensive AssessmentAging  
Open Uniform Comprehensive Assessment (.doc, 4 pp, 601 KB)Open Uniform Comprehensive Assessment (.pdf, 3 pp, 263 KB)
02HM002E
AG-002, PART IIUniform Comprehensive AssessmentAging  
Open Uniform Comprehensive Assessment (.doc, 26 pp, 2.1 MB)Open Uniform Comprehensive Assessment (.pdf, 26 pp, 2169 KB)
02HM003E
AG-003, PART IIIUniform Comprehensive AssessmentAging  
Open Title III Services Program Report (.doc, 1 pp, 1.2 MB)Open Title III Services Program Report (.pdf, 18 pp, 112 KB)
02MP003E
SUOA-S-019Title III Services Program ReportAging  
Open Personal Care Client Freedom of Choice (.doc, 1 pp, 50 KB)Open Personal Care Client Freedom of Choice Instructions (.pdf, 1 pp, 27 KB)
02MP005E
AG-010Personal Care Client Freedom of Choice Aging  
Open Ombudsman Volunteer Application (.doc, 2 pp, 677 KB)Open Ombudsman Volunteer Application (.pdf, 2 pp, 157 KB)
02OM003E
SUOA-S-77Ombudsman Volunteer ApplicationAging  
Applications  
Open Disclosure of Federal Tax Information (.doc, 2 pp, 231 KB)Open Disclosure of Federal Tax Information (.pdf, 2 pp, 120 KB)
03AD001E
N/ADisclosure of Federal Tax InformationChild Support  
Open File Transfer (.doc, 1 pp, 170 KB)Open File Transfer (.pdf, 1 pp, 149 KB)
03AD002E
N/AFile TransferChild Support  
Open Interest Disclosure Notice (.doc, 2 pp, 914 KB)Open Interest Disclosure Notice (.pdf, 2 pp, 156 KB)
03AD003E
N/AInterest Disclosure NoticeChild Support  
Open Application for Child Support Services (.doc, 18 pp, 1.5 MB)Open Application for Child Support Services (.pdf, 18 pp, 736 KB)
03EN001E
CSED-001Application for Child Support ServicesApplications  
Child Support  
Open Affidavit of Child Support Payments Received (.doc, 3 pp, 1.2 MB)Open Affidavit of Child Support Payments Received (.pdf, 3 pp, 185 KB)
03EN002E
CSED-1-AAffidavit of Child Support Payments ReceivedChild Support  
Open Summary of Support Order - English Version (.doc, 2 pp, 56 KB)Open Summary of Support Order - English Version (.pdf, 1 pp, 169 KB)
03EN003E
CSED-CCR SOSOSummary of Support Order - English VersionChild Support  
Open Income Withholding for Support (.doc, 3 pp, 1.2 MB)Open Income Withholding for Support (.pdf, 3 pp, 80 KB)Open Income Withholding for Support Instructions (.pdf, 8 pp, 74 KB)
03EN004E
N/AIncome Withholding for SupportChild Support  
Legal  
Open Child Support Computation for Period Prior to July 1, 2009 (.doc, 4 pp, 739 KB)Open Child Support Computation for Period Prior to July 1, 2009 (.pdf, 4 pp, 291 KB)Open Child Support Computation for Period Prior to July 1, 2009 Instructions (.pdf, 8 pp, 48 KB)
03EN005E
N/AChild Support Computation for Period Prior to July 1, 2009Child Support  
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Street address: Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd., Oklahoma City, OK 73105
Mailing address: P.O. Box 25352, Oklahoma City, OK 73125
(405) 521-3646