DSHS Form 10-328 "Residential Site Approval Request" - Washington

What Is DSHS Form 10-328?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-328 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-328 "Residential Site Approval Request" - Washington

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DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)
Residential Site Approval Request
PARTICIPANT NAME
AGENCY NAME
ADDRESS OF PROPOSED / CURRENT SITE
Site reviews must be conducted in accordance with DDA Policy 15.04, Standards for Community Protection Residential
Services and should consider specific participant offense patterns and other identified risk factors.
It may be necessary to identify the following:
The presence of minors and vulnerable adults residing in the immediate vicinity;
Proximity to schools, childcare centers, churches, playgrounds, recreational and activity fields, and other settings
where children or youth may play or congregate and which may be accessible from the residence or viewable from
within the house; and
The nearest police and fire departments and other essential community services.
From the interior of the house, note what is visible outside, including yards, public areas, and interiors of other houses. It
is important to conduct site observations at different times and different days of the week.
Section A: Check purpose of this review below.
New proposed site
Change in neighborhood
Change in housemate configuration
Other (specify):
Section B: Describe any identified risk factors and what measures will be taken to minimize the risk, including
environmental modifications. Attach additional information if necessary.
RISK FACTOR
MITIGATION PLAN
Section C: Description of environment (if proximity to minors is a risk factor, skip to Section D)
DATE AND DAY OF
TIME OF
DESCRIBE OBSERVATIONS
SIGNATURE OF OBSERVER
OBSERVATION
OBSERVATION
Page 1 of 2
RESIDENTIAL SITE APROVAL REQUEST
DSHS 10-328 (REV. 12/2021)
DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)
Residential Site Approval Request
PARTICIPANT NAME
AGENCY NAME
ADDRESS OF PROPOSED / CURRENT SITE
Site reviews must be conducted in accordance with DDA Policy 15.04, Standards for Community Protection Residential
Services and should consider specific participant offense patterns and other identified risk factors.
It may be necessary to identify the following:
The presence of minors and vulnerable adults residing in the immediate vicinity;
Proximity to schools, childcare centers, churches, playgrounds, recreational and activity fields, and other settings
where children or youth may play or congregate and which may be accessible from the residence or viewable from
within the house; and
The nearest police and fire departments and other essential community services.
From the interior of the house, note what is visible outside, including yards, public areas, and interiors of other houses. It
is important to conduct site observations at different times and different days of the week.
Section A: Check purpose of this review below.
New proposed site
Change in neighborhood
Change in housemate configuration
Other (specify):
Section B: Describe any identified risk factors and what measures will be taken to minimize the risk, including
environmental modifications. Attach additional information if necessary.
RISK FACTOR
MITIGATION PLAN
Section C: Description of environment (if proximity to minors is a risk factor, skip to Section D)
DATE AND DAY OF
TIME OF
DESCRIBE OBSERVATIONS
SIGNATURE OF OBSERVER
OBSERVATION
OBSERVATION
Page 1 of 2
RESIDENTIAL SITE APROVAL REQUEST
DSHS 10-328 (REV. 12/2021)
Section D: Description of environment (this section is for clients with proximity to minors as a risk factor. If this is not a
risk factor, skip this section).
The site visits should include Daytime (weekday, between 7:30 a.m. – 9 a.m.), Evening (weekday, between 2:30 p.m. –
6:30 p.m.), and Weekend (mid-day).
DATE AND DAY OF
TIME OF
DESCRIBE OBSERVATIONS
SIGNATURE OF OBSERVER
OBSERVATION
OBSERVATION
Did you screen for local childcare setting and schools?
Yes
No
Proximity of nearest school:
Proximity of nearest childcare center:
To the best of my knowledge, the above site location is an appropriate location for the listed participant given
their identified risk factors
SUBMITTED TO ADMINISTRATOR BY (IF NOT PREPARED BY ADMINISTRATOR):
DATE
APPROVED BY (RESIDENTIAL AGENCY ADMINISTRATOR):
DATE
Page 2 of 2
RESIDENTIAL SITE APROVAL REQUEST
DSHS 10-328 (REV. 12/2021)
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