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California Department of Developmental Services1600 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.
| 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 |
Due Process Mediation and Hearing Request This form is for any party seeking state level action on a disagreement related to a child under age 3 for a voluntary impartial mediation and due process hearing. (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 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 Complaint Investigation Request This form may be used by parents or any individual, agency or organization to file an Early Start Compliance Complaint. (More information) |
| DS 1831 English |
Self-Directed Services Criminal Record Declaration This form is required for all prospective and current Financial Management Services providers. (More information) |
| DS 1832 English |
Self-Directed Services Provider Information Release This form is release of information required for all prospective and current Financial Management Services providers. (More information) |
| DS 1833 English |
Self-Directed Services Criminal Record Clearance Action This form is required for all Financial Management Services providers to receive a criminal history records clearance. (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 (ICF/DD-CN) 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 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 2201 English |
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 2011 English |
DDS Video Tape Order Copies of video tapes are available for $5.00 each. (More information) |