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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 Ledger Sheet for Recipients Account (.doc, 1 pp, 737 KB)Open Ledger Sheet for Recipients Account (.pdf, 1 pp, 13 KB)Open Ledger Sheet for Recipients Account Instructions (.pdf, 1 pp, 17 KB)
08MA021E
ABCDM-099Ledger Sheet for Recipient's Account Medical  
Multiple Programs  
Open Medicaid Income Pension Trust (.pdf, 5 pp, 26 KB)Open Medicaid Income Pension Trust Instructions (.pdf, 2 pp, 31 KB)
08MA023E
M-011Medicaid Income Pension TrustMedical  
Open Report of Physicians Examination (.doc, 2 pp, 745 KB)Open Report of Physicians Examination Instructions (.pdf, 1 pp, 18 KB)
08MA080E
ABCDM-80Report of Physician's Examination Medical  
Open Notification Regarding Patient in a Nursing Facility (NF), Intermediate Care Facility for the Mentally Retarded (ICF/MR), or Hospice (.pdf, 2 pp, 31 KB)
08MA083E
ABCDM-083Notification Regarding Patient in a Nursing Facility (NF), Intermediate Care Facility for the Mentally Retarded (ICF/MR), or HospiceAging  
Medical  
Open Management of Recipients Funds (.pdf, 2 pp, 34 KB)
08MA084E
ABCDM-096Management of Recipient's FundsAging  
Medical  
Open Accounting - Recipients Personal Funds and Property (.doc, 1 pp, 667 KB)Open Accounting - Recipients Personal Funds and Property (.pdf, 1 pp, 11 KB)Open Accounting - Recipients Personal Funds and Property Instructions (.pdf, 1 pp, 23 KB)
08MA085E
ABCDM-96-AAccounting - Recipient's Personal Funds and Property Aging  
Medical  
Open Request for Benefits (.doc, 5 pp, 992 KB)Open Request for Benefits (.pdf, 5 pp, 249 KB)
08MP001E
PS-1Request for BenefitsApplications  
Multiple Programs  
Open Benefit Review Report (.doc, 7 pp, 1.1 MB)Open Benefit Review Report (.pdf, 7 pp, 378 KB)
08MP004E
FSS-BR-001Benefit Review ReportMultiple Programs  
Open Information for Benefit Review Reporters (.doc, 2 pp, 726 KB)Open Information for Benefit Review Reporters (.pdf, 2 pp, 57 KB)
08MP006E
N/AInformation for Benefit Review ReportersMultiple Programs  
Open Physician Assessment for TEFRA (.doc, 6 pp, 796 KB)Open Physician Assessment for TEFRA (.pdf, 6 pp, 410 KB)
08OA001E
TEFRA-001Physician Assessment for TEFRAMedical  
Open Request for Citizenship Verification (.doc, 1 pp, 1 MB)Open Request for Citizenship Verification (.pdf, 1 pp, 136 KB)
08OA005E
N/ARequest for Citizenship VerificationMedical  
Open Identity Affidavit (.doc, 1 pp, 189 KB)Open Identity Affidavit (.pdf, 1 pp, 132 KB)
08OA006E
N/AIdentity AffidavitMedical  
Open Time and Progress Report (.doc, 4 pp, 1.3 MB)Open Time and Progress Report (.pdf, 4 pp, 406 KB)
08TW013E
TW-13Time and Progress ReportTANF Work  
Open Confidential Intake Form (.doc, 6 pp, 818 KB)Open Confidential Intake Form (.pdf, 6 pp, 376 KB)
09AI002E
ACIS-2Confidential Intake FormApplications  
Field Operations  
Open Request for Approval of Leave (.doc, 2 pp, 693 KB)Open Request for Approval of Leave (.pdf, 2 pp, 193 KB)Open Request for Approval of Leave Instructions (.pdf, 3 pp, 25 KB)
10AD001E
ADM-1Request for Approval of LeaveFinance  
Personnel  
Open Claim Form (.doc, 2 pp, 722 MB)Open Claim Form (.pdf, 2 pp, 199 KB)Open Claim Form Instructions (.pdf, 2 pp, 48 KB)
10AD012E
ADM-12Claim FormContracts and Purchasing  
Open Child Care Claim (.doc, 2 pp, 982 KB)Open Child Care Claim (.pdf, 2 pp, 182 KB)
10AD121E
ADM-12-SChild Care ClaimChild Care  
Finance  
Open Automatic Deposit Transmittal (.doc, 2 pp, 880 KB)Open Automatic Deposit Transmittal (.pdf, 2 pp, 138 KB)
10OA073E
OPM-73Automatic Deposit TransmittalFinance  
Personnel  
Open Employee Satisfaction Survey (.pdf, 2 pp, 29 KB)
11PE002E
EAP-001Employee Satisfaction SurveyPersonnel  
Open Total Compensation Estimator for 2009 (.xls, 30 KB)
11PE003E
N/ATotal Compensation Estimator for 2009Personnel  
Open Application for Employment (.doc, 4 pp, 758 KB)Open Application for Employment (.pdf, 4 pp, 208 KB)Open Application Data Sheet Instructions (.pdf, 1 pp, 25 KB)
11PE012E
P-12Application for EmploymentApplications  
Personnel  
Open Reasonable Suspicion Checklist (.doc, 2 pp, 183 KB)Open Reasonable Suspicion Checklist (.pdf, 2 pp, 193 KB)
11PE094E
P-94Reasonable Suspicion ChecklistPersonnel  
Open Application Supplement (.doc, 2 pp, 903 KB)Open Application Supplement (.pdf, 2 pp, 224 KB)Open Application Supplement Instructions (.pdf, 1 pp, 13 KB)
11PE201E
P-1-DApplication SupplementApplications  
Open Request for a Fair Hearing (.doc, 2 pp, 674 KB)Open Request for a Fair Hearing (.pdf, 2 pp, 153 KB)Open Request for a Fair Hearing Instructions (.pdf, 1 pp, 18 KB)
13MP001E
H-001Request for a Fair HearingApplications  
Legal  
Multiple Programs  
Open Request for Review of Decision on Appeal by the Director of Department of Human Services (.doc, 1 pp, 848 KB)Open Request for Review of Decision on Appeal by the Director of Department of Human Services (.pdf, 1 pp, 127 KB)Open Request for Review of Decision on Appeal by the Director of Department of Human Services Instructions (.pdf, 1 pp, 18 KB)
13MP003E
H-2Request for Review of Decision on Appeal by the Director of Department of Human ServicesLegal  
Multiple Programs  
Open Withdrawal of Request for Hearing (.doc, 1 pp, 522 KB)Open Withdrawal of Request for Hearing Instructions (.pdf, 1 pp, 17 KB)
13MP004E
H-3Withdrawal of Request for Hearing Legal  
Multiple Programs  
Open Resource Family Request for a Fair Hearing (.doc, 1 pp, 681 KB)Open Resource Family Request for a Fair Hearing Instructions (.pdf, 1 pp, 18 KB)
13MP005E
H-4Resource Family Request for a Fair Hearing Legal  
Multiple Programs  
Open Discrimination Complaint Form - Client or Vendor (.doc, 1 pp, 545 KB)Open Discrimination Complaint Form - Client or Vendor (.pdf, 1 pp, 81 KB)Open Discrimination Complaint Form - Client or Vendor Instructions (.pdf, 1 pp, 12 KB)
14CR001E
OCR-001Discrimination Complaint Form - Client or VendorCivil Rights  
Open Request for Reasonable Accommodation - Employee or Applicant for Employment (.doc, 1 pp, 668 KB)
14CR003E
ADA-1Request for Reasonable Accommodation - Employee or Applicant for EmploymentCivil Rights  
Open Request for Reasonable Accommodation - Client or Applicant for Services (.doc, 1 pp, 668 KB)
14CR004E
ADA-2Request for Reasonable Accommodation - Client or Applicant for ServicesCivil Rights  
Open Non-Discrimination Compliance (.doc, 1 pp, 658 KB)Open Non-Discrimination Compliance (.pdf, 1 pp, 132 KB)Open Non-Discrimination Compliance Instructions (.pdf, 1 pp, 13 KB)
14CR007E
AA-7Non-Discrimination ComplianceCivil Rights  
Open Discrimination Complaint Form - Employee (.doc, 1 pp, 929 KB)Open Discrimination Complaint Form - Employee (.pdf, 1 pp, 129 KB)
14CR019E
P-019Discrimination Complaint Form - EmployeeCivil Rights  
Open Office of Client Advocacy Intake Referral (.doc, 2 pp, 210 KB)Open Office of Client Advocacy Intake Referral (.pdf, 2 pp, 213 KB)Open Office of Client Advocacy Intake Referral Instructions (.pdf, 1 pp, 23 KB)
15GN001E
OCA-001Office of Client Advocacy Intake ReferralApplications  
Client Advocacy  
Open Local Grievance Coordinator (LGC) Worksheet (.doc, 2 pp, 100 KB)Open Local Grievance Coordinator (LGC) Worksheet (.pdf, 1 pp, 129 KB)
15GR002E
OCA-GR-001-ALocal Grievance Coordinator (LGC) WorksheetClient Advocacy  
Open Notice of Grievance Rights - Hissom Class Members (.doc, 2 pp, 661 KB)Open Notice of Grievance Rights - Hissom Class Members (.pdf, 1 pp, 67 KB)
15GR007E
OCA-GR-3-ANotice of Grievance Rights - Hissom Class MembersClient Advocacy  
Open Quarterly Grievance Report (.doc, 2 pp, 600 KB)Open Quarterly Grievance Report (.pdf, 2 pp, 76 KB)
15GR010E
OCA-GR-006Quarterly Grievance ReportClient Advocacy  
Open Designation of Local Grievance Coordinator - Facilities and Provider Agencies (.doc, 1 pp, 508 KB)Open Designation of Local Grievance Coordinator - Facilities and Provider Agencies (.pdf, 1 pp, 65 KB)
15GR021E
OCA-GR-10Designation of Local Grievance Coordinator - Facilities and Provider AgenciesClient Advocacy  
Open Bodily Injury Chart (.pdf, 1 pp, 79 KB)
15IV002E
OCA-002Bodily Injury ChartClient Advocacy  
Open Caretaker Conduct Review Report - Office of Juvenile Affairs (OJA) Operated Facility (.doc, 4 pp, 121 KB)Open Caretaker Conduct Review Report - Office of Juvenile Affairs (OJA) Operated Facility (.pdf, 3 pp, 149 KB)
15IV003E
OCA-007-ACaretaker Conduct Review Report - Office of Juvenile Affairs (OJA) Operated FacilityClient Advocacy  
Open Rights and Responsibilities of Accused Caretakers (.doc, 2 pp, 665 KB)Open Rights and Responsibilities of Accused Caretakers (.pdf, 2 pp, 127 KB)
15IV005E
OCA-4-ARights and Responsibilities of Accused CaretakersClient Advocacy  
Open Caretaker Conduct Review Report - OKDHS Operated Facility (.doc, 3 pp, 702 KB)
15IV007E
OCA-7Caretaker Conduct Review Report - OKDHS Operated FacilityClient Advocacy  
Open Caretaker Conduct Review Report - Residential Facilities (.doc, 3 pp, 120 KB)Open Caretaker Conduct Review Report - Residential Facilities (.pdf, 3 pp, 159 KB)
15IV009E
OCA-007-BCaretaker Conduct Review Report - Residential FacilitiesClient Advocacy  
Open Web Request (.doc, 2 pp, 855 KB)Open Web Request (.pdf, 2 pp, 155 KB)
16AD008E
N/AWeb RequestGeneral Use  
Web  
Open Web Content Plan - Annual Content Plan (.doc, 1 pp, 171 KB)Open Web Content Plan - Annual Content Plan (.pdf, 1 pp, 117 KB)
16AD009E
N/AWeb Content Plan - Annual Content PlanGeneral Use  
Open Notice Regarding Statements during Internal Investigations (.doc, 1 pp, 717 KB)Open Notice Regarding Statements during Internal Investigations (.pdf, 1 pp, 118 KB)
19IV002E
N/ANotice Regarding Statements during Internal InvestigationsClient Advocacy  
Personnel  
Open Request for Document Assistance (.doc, 3 pp, 780 KB)Open Request for Document Assistance (.pdf, 3 pp, 254 KB)
21AD083E
ADM-83-ARequest for Document AssistanceGeneral Use  
Open OKDHS Document Category Codes (.pdf, 5 pp, 114 KB)
21AX004E
APPENDIX ST004EOKDHS Document Category CodesGeneral Use  
Open Application for Volunteer Service (.doc, 3 pp, 723 KB)Open Application for Volunteer Service (.pdf, 3 pp, 177 KB)
22VL005E
VOL-5Application for Volunteer ServiceApplications  
General Use  
Volunteerism  
Open Referral for and Acceptance of Volunteer Services (.doc, 1 pp, 521 KB)Open Referral for and Acceptance of Volunteer Services Instructions (.pdf, 1 pp, 21 KB)
22VL008E
VOL-8Referral for and Acceptance of Volunteer Services Volunteerism  
Open Order For Anniversary Cookbook (.doc, 1 pp, 748 KB)
22VL010E
VOL-10Order For Anniversary CookbookVolunteerism  
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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