Welcome to the California Department of Developmental Services
DDS Logo California Department of Developmental Services
1600 9th Street
P. O. Box 944202
Sacramento, CA 94244-2020

Info: (916) 654-1690
TTY: (916) 654-2054

DDS Forms

The Department of Developmental Services' forms are in Adobe Acrobat portable document format (PDF). A majority of the fill-in Developmental Services (DS) forms may be "Save" using the free Adobe Reader 7 or later. These forms can be completed online but cannot be submitted electronically. After completion, they should be printed and mailed to the appropriate party.

Department of Developmental Services Forms
DDS FORMS DESCRIPTION
  Home and Community Based-Services Provider Agreement
This form is to be completed by all vendors whose proposed service is eligible for Medicaid Waiver reimbursement.
Work Services Cost Statement Forms and Work Services Forms (More information)
DS 2
English
Transportation Cost Statement
This form is to be completed by vendors and forward to the department and regional centers.
DS 43
English | Spanish
Request to Inspect Public Record
This is a form that the Department asks be completed by persons requesting records pursuant to the Public Records Act or Information Practices Act. This form assists the Department in responding to such requests.
DS 254
English | Spanish
Consumer Advisory Committee Membership Application
This application is use to apply for membership for the Department's Consumer Advisory Committee. (Consumer Advisory Committee)
DS 255
English | Spanish
Welfare and Institution Code Section 4731 Complaint Form Investigation Request
This form may be used by a consumer of a regional center or developmental center, or a representative acting on behalf of a consumer, to file a W&I Code Section 4731 complaint against a regional center, developmental center, or service provider vendored by the regional center. This form is optional and may be used as guidance in writing your complaint letter. (More information)
DSP 304
English | Spanish
Rights of Individuals with Developmental Disabilities
This form is use by the developmental centers, regional centers, and various community services programs.
DS 306
English
Denial of Rights Report
This form is used by Residential Facilities and Developmental Centers' for denial of client's personal rights.
DS 1214
English | Spanish
Parental Fee Program Home Leave Credits
This form is used by parent(s) of clients to keep track of home leave credits for hours/days spent away from group home.
DS 1235
English | Spanish
Family Financial Statement
This form is used by the Parental Fee Program staff (Headquarters) and Regional Center social workers to assess monthly fees paid by parents for minor clients receiving regional center services.
DS 1802
English| Spanish
Early Start Due Process Hearing Requests
This form is used to resolve disagreements between parents and a regional center or a local education agency related to a proposal or refusal for identification, evaluation, assessment, placement, or services. (More information)
DS 1803
English | Spanish
Notice of Proposed Action
This form is completed by the regional center to advise an applicant/recipient of regional center services of any action the regional center proposes to take which may affect their services and their right to appeal. (More information and languages)
DS 1804
English | Spanish
Fair Hearing Request Withdraw
This form is to be completed by the applicant/recipient of regional center services to withdraw his/her request for a fair hearing. (More information and languages)
DS 1805
English | Spanish
Fair Hearing Request
This form is to be completed by the applicant/recipient of regional center services, or his/her authorized representative, if an informal meeting, and/or mediation, and/or fair hearing is desired. (More information and languages)
DS 1808
English |Spanish
Early Start Mediation Conference Requests
This form is used to informally resolve disagreements between a parent, as defined in law, and a regional center or a local education agency related to any alleged violation of federal or state statutes/regulation governing California’s Early Start Program, including eligibility and services, or related to a proposal or refusal for identification, evaluation, assessment, placement, or services. (More information)
DS 1811
English | Spanish
Respite Services Billing Form
This form is to be completed by a vendored family member who uses an individual worker to provide respite services, and is to be submitted to the regional center with the billings/invoices for the billing period the form covers. (More information)
DS 1827
English | Spanish
Early Start Compliance Complaints Process
This form may be used by parents or any individual, agency or organization to file an Early Start Compliance Complaint. (More information)
DS 1851
English
Specialized Procedures Request Cover Sheet
This cover sheet is used when submitting a request to DDS for the approval of the performance of a specific procedure for the ICF/DD-N. (More information)
DS 1852
English
Health Facility Program Plan Application
This form is used for processing transactions involving the operations of Intermediate Care Facilities (ICF) for the Developmentally Disabled (ICF/DD), Habilitative (ICF/DD-H), Nursing (ICF/DD-N) and Continuous Nursing Care (DD-CNC) Programs. More information)
DS 1853
English
Training Program for ICF/DD-N Attendant
This form is used when submitting a request to DDS for the approval of a developed lesson plan for each topic under Module 1-4 (More information)
DS 1890
English | Spanish
Vendor Application Form
This form is to be completed by service providers as part of the vendorization process. (More information)
DS 1891
English | Spanish
Applicant/Vendor Disclosure Statement
This form is to be completed by every applicant or vendor and submitted with their vendor application packet for vendorization or upon request of the vendoring regional center. (More information)
DS 1897
English
Community-Based Day Programs Cost Statement
This form is to be completed by vendors and forward to the department and regional centers.
DS 1897B
English
In-Home Respite Cost Statement
This form is to be completed by vendors and forward to the department and regional centers.
DS 2007
English | Spanish
Citizen Comments and Complaint
This form is for problems or complaints that do not fit one of the formal processes. You may also use the form to acknowledge any individual, regional center, developmental center, or service provider for noteworthy service or conduct. (More information)
DS 2011
English | Spanish
DDS Video Order Form
Copies of video are in DVD format and are available for $5.00 each. (More information)
DS 2201
English | Spanish
Home and Community Based Services Waiver Consumer Standard Annual Review
This form is used by Regional Centers to document the annual review of Home and Community Based Services Waiver, consumers’ Individual Program Plan (IPP) and Client Development Evaluation Report (CDER). Completion of this form is required only if a new IPP is not developed as part of the annual review process.
DS 3770
English
Medicaid Waiver Eligibility Record
Regional center service coordinators use this form to review a consumer’s Home and Community Based Services (HCBS) waiver eligibility certification, re-certification, qualifying conditions and any short-term absences.
DS 5862
English | Spanish
DDS Parental Verification for Receipt of Behavioral Services
The form is to be used by the parent or legal guardian of children under the age of 18 years and who reside in the family home. By signing the form, the parent or legal guardian verifies that behavioral services, on behalf of their child, have occurred.(Chinese | Russian | Tagalog | Vietnamese)
DS 6009
English | Spanish
Annual Family Program Fee Registration Form
This form is used by the regional centers to register families for the AFPF program and to document both the assessed fee amount and the date of the fee assessment. It is also used by the regional centers for referrals, and post referral change notification, to DDS.
DS 6010
English | Spanish
Annual Family Program Fee Payment Form
This is the AFPF remittance form provided by the regional center to the family. The regional center inputs the fee assessment date and amount assessed. The family retains a portion of the form for their records and mails a portion with their payment to DDS to ensure proper payment crediting.
(Chinese | Russian | Tagalog | Vietnamese)
DS 6011
English | Spanish
Annual Family Program Fee Payment Form - Second Notice
This is similar to the DS 6010 and is sent by the regional center to the family as a second notice reminder when the family's assessed fee has not been paid. (Chinese | Russian | Tagalog | Vietnamese)
DS 6016
English
Conflict of Interest Reporting Statement
This statement is to be completed by regional center employees, contractors, agents and consultants who have authority to act on behalf of the regional center. The purpose of this statement is to assist an individual, the regional center and the Department to identify any relationships, positions or circumstances which may create a conflict of interest between an individual’s regional center duties and obligations, and any other financial interests and/or relationships that an individual may have.
DS 6017 New Form
English
Media Access Request and Agreement
This form is for media to request access to the Department of Developmental Services' Developmental Centers and State-Operated Community Facilities.
 
 
Last Updated: 2/6/2014