DSS Forms

Staff Related

  • Discipline Document
  • Employee Physical Examination Form
  • Employee Satisfaction Survey
  • Employee Suspension Checklist
  • Fax Transmittal Sheet – Berks
  • Fax Transmittal Sheet – Luzerne
  • Fax Transmittal Sheet – Schuylkill
  • Key Sign-Off.doc
  • New Hire Shadowing Schedule
  • Orientation Check-Off List for New Employees (ADC)
  • P&P QM Sign Off
  • PA DPW Medication Administration Observation Sheet
  • PA DPW Medication Administration Record Review Sheet
  • PA DPW Student Certification Form
  • Paid Time Off Request Form
  • Performance Improvement Plan
  • Personnel Action Request
  • PreService Training Record
  • ReDCo Expense Voucher 10-1-12
  • Suspension Memo
  • Training Verification Form
  • Transfer Request Form

Misc Programming

  • Access Request Form – 11-01-2015
  • Civil Rights Compliance Participant Awareness Form
  • Day Program Attendance Sheet
  • Discharge Assessment
  • Documentation of Use of CPI Disengagement Skills
  • Family Satisfaction Survey
  • Fire and Emergency Evacuation Drill Report / Quarterly Training (ADC)
  • Grievance Procedure Letter – ReDCo
  • HIPAA PHI Incident Reporting Form – 11-01-2015
  • Home Community Based Services Time & Attendance Sheet
  • Informed Consent – Human Rights Committee – Plan Revision
  • In-Home Fire Training for New Admissions
  • Integrated Support Checklist
  • Internal Review Committee
  • Mandatory Abuse Report
  • News Release/Photo Release of Information
  • Non-Discrimination in Services
  • Non-Discrimination Policy Statement Equal Employment Opportunity
  • Notification of Illness
  • Outcome Monthly Data Collection and Outing Form
  • Participant Rights Acknowledgement Form
  • Participant Rights Acknowledgement Form — Spanish
  • Pennsylvania Department of Health List of Reportable Diseases
  • Permanent Record Disposal Authorization
  • Psychosocial Assessment
  • Quality Assurance
  • Reporting Matrix
  • Responsibility for Reporting/Investigating Regulations
  • SH/AIS User Guide
  • Travel Planning Document