AGING AND DISABILITY SERVICES ADMINISTRATION
Nurse Delegation Program - Forms
The following are the mandatory forms to be used for all DSHS contracted nurse delegators.
- 10-217 Nurse Delegation: Credentials and Training Verification
- 13-678, Nurse Delegation: Consent for Delegation Process (page 1)
- 13-678, Nurse Delegation: Instructions for Nursing Task (page 2)
- 13-678A Nurse Delegation: PRN Medication
- 13-678B Nurse Delegation: Assumption of Delegation
- 13-680 Nurse Delegation: Rescinding Delegation
- 13-681 Nurse Delegation: Change in Medical Orders
- 14-484 Nurse Delegation: Nursing Visit
