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Oklahoma Department of
Human Services
Oklahoma Department of Human Services
75th Anniversary
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Brighter Futures
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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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.
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355 forms found    Page 1  2  3  4  5  6  7  8   
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, 321 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, 101 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, 186 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, 278 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, 190 KB)
02AG006E
AG-029Voluntary Withdrawal of Title III ProjectAging  
Open Cash Disbursements Journal (.xls, 1 pp, 148 KB)
02AG011E
SUOA-S-10Cash Disbursements JournalAging  
Open Cash Disbursements Journal (.xls, 182 KB)
02AG012E
SUOA-S-11Cash Disbursements JournalAging  
Open Equipment Inventory (.doc, 2 pp, 518 KB)Open Equipment Inventory (.pdf, 2 pp, 229 KB)
02AG013E
SUOA-S-16Equipment InventoryAging  
Open In-Kind Travel Expense Voucher (.doc, 1 pp, 1336 KB)Open In-Kind Travel Expense Voucher (.pdf, 1 pp, 354 KB)
02AG014E
SUOA-S-017In-Kind Travel Expense VoucherAging  
Open Organization Financial Report (.doc, 1 pp, 852 KB)Open Organization Financial Report (.pdf, 1 pp, 175 KB)Open Organization Financial Report Instructions (.pdf, 1 pp, 22 KB)
02AG015E
SUOA-S-20Organization Financial ReportAging  
Open Nutrition Project Attendance Form (.doc, 2 pp, 757 KB)Open Nutrition Project Attendance Form (.pdf, 2 pp, 237 KB)
02AG016E
SUOA-S-032Nutrition Project Attendance FormAging  
Open Individual Attendance Record (.doc, 2 pp, 269 KB)Open Individual Attendance Record (.pdf, 2 pp, 708 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, 175 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, 432 KB)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, 181 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, 497 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, 246 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, 358 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, 187 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, 196 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, 218 KB)
02AG026E
SUOA-S-081Audit Report TransmittalAging  
Open Area Agency Quarterly Summary of Program Income (.doc, 1 pp, 147 KB)Open Area Agency Quarterly Summary of Program Income (.pdf, 1 pp, 159 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, 200 KB)
02AG028E
AG-030Management PlanAging  
Open Personal Care Plan (.doc, 4 pp, 92 KB)Open Personal Care Plan (.pdf, 4 pp, 172 KB)Open Personal Care Plan Instructions (.pdf, 1 pp, 14 KB)
02AG029E
AG-004Personal Care PlanAging  
Open Personal Care Planning Schedule (.doc, 1 pp, 1.5 MB)Open Personal Care Planning Schedule (.pdf, 4 pp, 321 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, 154 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, 163 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)Open Personal Care Agency Referral (.pdf, 1 pp, 130 KB)
02AG033E
AG-008Personal Care Agency ReferralAging  
Open Personal Care Progress Notes (.doc, 2 pp, 228 KB)Open Personal Care Progress Notes (.pdf, 2 pp, 360 KB)Open Personal Care Progress Notes Instructions (.pdf, 1 pp, 21 KB)
02AG039E
AG-022Personal Care Progress NotesAging  
Open Personal Care Assistant (PCA) Supervisor Visit (.doc, 2 pp, 122 KB)Open Personal Care Assistant (PCA) Supervisor Visit (.pdf, 2 pp, 255 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 (.pdf, 2 pp, 267 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 ServicesAging  
Open State Plan Personal Care (SPPC) Progress Notes (.doc, 4 pp, 993 KB)Open State Plan Personal Care (SPPC) Progress Notes (.pdf, 4 pp, 416 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, 144 KB)
02AG047E
N/ARecruitment Incident ReportAging  
Open Notice to Comply (.doc, 2 pp, 661 KB)Open Notice to Comply (.pdf, 2 pp, 140 KB)
02AG048E
N/ANotice to ComplyAging  
Open Adult Day Service Invoice (.doc, 1 pp, 82 KB)Open Adult Day Service Invoice (.pdf, 1 pp, 119 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, 1.0 MB)Open Adult Day Services Monthly Report (.pdf, 2 pp, 174 KB)
02AS002E
ADS-MR-1Adult Day Services Monthly ReportAdult Day Services  
Open Adult Day Services Referral/Application (.doc, 3 pp, 664 KB)Open Adult Day Services Referral/Application (.pdf, 3 pp, 184 KB)Open Adult Day Services Referral/Application Instructions (.pdf, 1 pp, 16 KB)
02AS003E
ADS-RA-1Adult Day Services Referral/ApplicationAdult Day Services  
Aging  
Applications  
Open Service/Attendance/Claim Record (.doc, 1 pp, 1.0 MB)Open Service/Attendance/Claim Record (.pdf, 1 pp, 711 KB)Open Service/Attendance/Claim Record Instructions (.pdf, 1 pp, 20 MB)
02AS004E
AS-ADS-001Service/Attendance/Claim RecordAdult Day Services  
Aging  
Open Service Team Release of Information (.doc, 1 pp, 249 KB)Open Service Team Release of Information (.pdf, 1 pp, 144 KB)Open Service Team Release of Information Instructions (.pdf, 1 pp, 12 KB)
02CB005E
ADV5Service Team Release of InformationAdvantage  
Open Provider Communication (.doc, 1 pp, 245 KB)Open Provider Communication (.pdf, 1 pp, 151 KB)Open Provider Communication Instructions (.pdf, 1 pp, 18 KB)
02CB009E
ADV9Provider CommunicationAdvantage  
Open Service Plan Cost Sheet (.doc, 2 pp, 281 KB)Open Service Plan Cost Sheet (.pdf, 2 pp, 286 KB)Open Service Plan Cost Sheet Instructions (.pdf, 2 pp, 27 KB)
02CB011E
ADV6EService Plan Cost SheetAdvantage  
Open Service Plan Cost Sheet Addendum (.doc, 2 pp, 284 KB)Open Service Plan Cost Sheet Addendum (.pdf, 2 pp, 296 KB)Open Service Plan Cost Sheet Addendum Instructions (.pdf, 4 pp, 31 KB)
02CB012E
ADV6E1Service Plan Cost Sheet AddendumAdvantage  
Open Service Plan Goals (.doc, 6 pp, 279 KB)Open Service Plan Goals (.pdf, 6 pp, 274 KB)Open Service Plan Goals Instructions (.pdf, 2 pp, 18 KB)
02CB013E
N/AService Plan GoalsAdvantage  
Open Services Backup Plan (.doc, 2 pp, 287 KB)Open Services Backup Plan (.pdf, 2 pp, 260 KB)Open Services Backup Plan Instructions (.pdf, 2 pp, 31 KB)
02CB014E
ADV300Services Backup PlanAdvantage  
Open Discharge Evaluation (.doc, 1 pp, 937 KB)Open Discharge Evaluation (.pdf, 1 pp, 151 KB)Open Discharge Evaluation Instructions (.pdf, 1 pp, 17 KB)
02CB015E
ADV15Discharge EvaluationAdvantage  
Open Notice of Change in ADvantage Services (.doc, 1 pp, 1.0 MB)Open Notice of Change in ADvantage Services (.pdf, 1 pp, 156 KB)Open Notice of Change in ADvantage Services Instructions (.pdf, 1 pp, 13 KB)
02CB016E
N/ANotice of Change in ADvantage ServicesAdvantage  
Open Environmental Modification Decision Tool (.doc, 2 pp, 918 KB)Open Environmental Modification Decision Tool (.pdf, 2 pp, 253 KB)Open Environmental Modification Decision Tool Instructions (.pdf, 2 pp, 19 KB)
02CB031E
N/AEnvironmental Modification Decision ToolAdvantage  
Open Environmental Modification Permission and Verification (.doc, 2 pp, 322 KB)Open Environmental Modification Permission and Verification (.pdf, 2 pp, 185 KB)Open Environmental Modification Permission and Verification Instructions (.pdf, 2 pp, 17 KB)
02CB032E
N/AEnvironmental Modification Permission and VerificationAdvantage  
Open Level of Function and Environment Assessment (.doc, 4 pp, 943 KB)Open Level of Function and Environment Assessment (.pdf, 4 pp, 269 KB)Open Level of Function and Environment Assessment Instructions (.pdf, 3 pp, 39 KB)
02CB033E
N/ALevel of Function and Environment AssessmentAdvantage  
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Last Updated:  1/30/2012
Oklahoma Department of Human Services
Street address: 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
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