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Forms: Numeric List 
F-40000 Through F-49999

This numeric list contains forms that are available from this site. A PDF - Fillable form can be filled in using your computer and then printed; see About PDF Forms. Microsoft Word - Fillable or Excel forms, can be filled in, saved, and transmitted electronically.  You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Key word explanations for Form Type and Other Location columns.

Division Prefix / Old Form Number Assigned Form Number Form Title Form Type Other Location Language
DPH-40019 F-40019 Affirmation of Identity, Residency, and/or Income (PDF, 35 KB) PDF None English
DPH-40019S F-40019S Affirmation of Identity, Residency, and/or Income - Spanish (PDF, 18 KB) PDF None Spanish
DPH-40028R F-40028R CSFP Ineligibility, Termination, and Waiting List - Russian Paper Form Center Russian
DPH-40028S F-40028S CSFP Ineligibility, Termination, and Waiting List - Spanish Paper Form Center Spanish
DPH-40034 F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing Word None English
DPH-40036 F-40036 Wisconsin Women, Infant, and Children (WIC) Program Vendor Agreement (PDF, 45 KB) PDF None English
DPH-40040 F-40040 Envelope - No. 9 Vendor and Integrity Unit Address Paper Form Center English
DPH-40041 F-40041 CSFP Certification & Food Package Pick-Up For Seniors (PDF, 21 KB) PDF Form Center English
DPH-40041H F-40041H CSFP Certification & Food Package Pick-Up For Seniors - Hmong (PDF, 22 KB) PDF Form Center Hmong
DPH-40041R F-40041R CSFP Certification & Food Package Pick-Up For Seniors - Russian (PDF, 156 KB) PDF Form Center Russian
DPH-40041S F-40041S CSFP Certification & Food Package Pick-Up For Seniors - Spanish (PDF, 156 KB) PDF Form Center Spanish
DPH-40044H F-40044H CSFP Rights and Responsibilities - Hmong Paper Form Center Hmong
DPH-40044R F-40044R CSFP Rights and Responsibilities - Russian Paper Form Center Russian
DPH-40044S F-40044S CSFP Rights and Responsibilities - Spanish Paper Form Center Spanish
DPH-40052A F-40052A WIC Program Breast Pump Order Request (PDF, 116 KB) PDF None English
DPH-40052A F-40052A WIC Program Breast Pump Order Request Word None English
DPH-40053 F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training (PDF, 10 KB) PDF None English
DPH-40054 F-40054 Confidential Birth Defects Registry Report (PDF, 188 KB) PDF None English
DPH-40056 F-40056 Birth Defects Prevention and Surveillance System User Security and Confidentiality Agreement (PDF, 21 KB) PDF None English
DPH-40057 F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program (PDF, 32 KB) PDF None English
DPH-40058 F-40058 Verification of Transfer of USDA Commodities Word Program English
DPH-40059 F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Monthly (PDF, 32 KB) PDF None English
DPH-40059 F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Monthly Word None English
DPH-40059H F-40059H The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Hmong Word None Hmong
DPH-40059R F-40059R The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Russian Word None Russian
DPH-40059S F-40059S The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Spanish (PDF, 40 KB) PDF None Spanish
DPH-40059S F-40059S The Emergency Food Assistance Program (TEFAP) Eligibility Certification - Spanish Word None Spanish
DPH-40060 F-40060 The Emergency Food Assistance Program Commodities Inventory Report Word Program English
DPH-40060A F-40060A The Emergency Food Assistance Program Commodities at Pantry, Soup Kitchen, and Shelter Word Program English
DPH-40061 F-40061 The Emergency Food Assistance Program (TEFAP) Commodities Inventory Word None English
DPH-40062 F-40062 The Emergency Food Assistance Program TEFAP and CSFP Commodity Loss Report Word None English
DPH-40063 F-40063 The Emergency Food Assistance Program (TEFAP) Commodities Complaint Word None English
DPH-40064 F-40064 Transfer of The Emergency Food Assistance Program (TEFAP) Commodities between EFO's Word None English
DPH-40065 F-40065 Storage Facility Review Monitoring Report Word None English
DPH-40066 F-40066 The Emergency Food Assistance Program (TEFAP) Word None English
DPH-40070 F-40070 Emergency Feeding Organization (EFO) Monitoring Instrument Word None English
DPH-40071 F-40071 Children's Physical Activity Chart (PDF, 18 KB) PDF None English
DPH-40072 F-40072 8 Week Activity Log (PDF, 19 KB) PDF None English
DPH-40073 F-40073 Monthly Physical Activity Sheet (PDF, 61 KB) PDF None English
DPH-40074 F-40074 Annual Physical Activity Record (PDF, 27 KB) PDF None English
DPH-40075 F-40075 Pedometer Walking Program (PDF, 83 KB) PDF None English
DPH-40076 F-40076 WIC Income Statement (PDF, 85 KB) PDF Form Center English
DPH-40076S F-40076S WIC Income Statement - Spanish (PDF, 103 KB) PDF Form Center Spanish
DPH-40082 F-40082 WIC Program Civil Rights Discrimination Complaint (PDF, 27 KB) PDF None English
DPH-40082S F-40082S WIC Program Civil Rights Discrimination Complaint - Spanish (PDF, 26 KB) PDF None Spanish
DPH-40085 F-40085 WIC Program Notice of Ineligibility (PDF, 48 KB) PDF None English
DPH-40085S F-40085S WIC Program Notice of Ineligibility - Spanish (PDF, 58 KB) PDF None Spanish
DPH-40089 F-40089 Receipt For Confiscated WIC Checks Word Program English
DPH-40092 F-40092 Physical Activity Zone (PDF, 229 KB) PDF None English
DPH-40093 F-40093 Annual ROSIE User Security and Confidentiality Agreement (PDF, 132 KB) PDF None English
DPH F-40093 Annual ROSIE User Security and Confidentiality Agreement Word None English
DPH-40094 F-40094 WIC Program Lost or Stolen Check Replacement Agreement (PDF, 88 KB) PDF None English
DPH-40094 F-40094 WIC Program Lost or Stolen Check Replacement Agreement Word None English
DPH-40094 F-40094H WIC Program Lost or Stolen Check Replacement Agreement - Hmong (DPF, 20 KB) PDF None Hmong
DPH F-40094H WIC Program Lost or Stolen Check Replacement Agreement - Hmong Word None Hmong
DPH-40094 F-40094S WIC Program Lost or Stolen Check Replacement Agreement - Spanish (PDF, 19 KB) PDF None Spanish
DPH F-40094S WIC Program Lost or Stolen Check Replacement Agreement - Spanish Word None Spanish
DPH-40095 F-40095 WIC Program Repayment Agreement With Proxy Designation (PDF, 111 KB) PDF None English
DPH F-40095H WIC Program Repayment Agreement With Proxy Designation - Hmong (PDF, 17 KB) PDF None Hmong
DPH F-40095S WIC Program Repayment Agreement With Proxy Designation - Spanish (PDF, 17 KB) PDF None Spanish
DPH-40096 F-40096 WIC Program Repayment Agreement (PDF, 65 KB) PDF None English
DPH F-40096H WIC Program Repayment Agreement - Hmong (PDF, 17 KB) PDF None Hmong
DPH F-40096S WIC Program Repayment Agreement - Spanish (PDF, 17 KB) PDF None Spanish
DPH-40097 F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement (PDF, 82 KB) PDF None English
DPH-40098 F-40098 Worksite Wellness Kit Survey and Request (PDF, 147 KB) PDF None English
DPH-40098 F-40098 Worksite Wellness Kit Survey and Request Word None English
DPH-40103 F-40103 FMNP Senior Eligbility Agreement Paper Form Center English
DPH-40103H F-40103H FMNP Senior Eligbility Agreement - Hmong Paper Form Center English
DPH-40103S F-40103S FMNP Senior Eligbility Agreement - Spanish Paper Form Center English
DPH-40104 F-40104 WIC Retail Vendor Annual Food Sales Survey (PDF, 72 KB) PDF None English
DPH-00108 F-40108 Retail Vendor Application Amendment Women, Infant, and Children (WIC) (PDF, 261 KB) PDF None English
DPH-40123A F-40123A Hearing Screening Postcard - English Paper Form Center English
DPH-40123AH F-40123AH Hearing Screening Postcard - Hmong Paper Form Center English
DPH-40123AS F-40123AS Hearing Screening Postcard - Spanish Paper Form Center English
DPH-00303 F-40303 Early Childhood Caries Prevention Screening (PDF, 117 KB) PDF None English
DPH-00309 F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB) PDF None English
DPH-00309A F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB) PDF None English
DPH-00310 F-40310 Adult Oral Health Screening (PDF, 176 KB) PDF None English
DPH-00335 F-40335 Pre-School Oral Health Preliminary Exam and Prevention Services (PDF, 439 KB) PDF None English
DPH-42000 F-42000 Vaccine Order (PDF, 34 KB) PDF None English
DPH-42001 F-42001 Tuberculosis Suspect Case Data (PDF, 226 KB) PDF None English
DPH-42002 F-42002 Warning: Do Not Unplug Refrigerator - Label Paper Program English
DPH-42007 F-42007 Mail Label 3 X 4 - Immunization Program Paper Program English
DPH-42010 F-42010 Interjurisdictional Tuberculosis Notification (PDF, 24 KB) PDF None English
DPH-42011 F-42011 Interjurisdictional Tuberculosis Notification - Follow-up (PDF, 87 KB) PDF None English
DPH-42016 F-42016 Authorization for Release of Confidential HIV Test Results (PDF, 512 KB) PDF None English
DPH F-42016H Authorization for Release of Confidential HIV Test Results - Hmong (PDF, 41 KB) PDF None Hmong
DPH F-42016S Authorization for Release of Confidential HIV Test Results - Spanish (PDF, 242 KB) PDF None Spanish
DPH-42017 F-42017 Wisconsin Initial Refugee Health Assessment (PDF, 366 KB) PDF None English
DPH-42017 F-42017 Wisconsin Initial Refugee Health Assessment Word None English
DPH-42019 F-42019 Written Informed Consent For Additional Tests Follow-up On Discordant Rapid and Confirmatory Test Results (PDF, 95 KB) PDF None English
DPH-42023 F-42023 Vaccine Celsius Temperature Log (PDF, 2.4 MB) PDF None English
DPH-42024 F-42024 Vaccine Fahrenheit Temperature Log (PDF, 2.4 MB) PDF None English
DPH-42026 F-42026 Reimbursement Request Wisconsin AIDS/HIV Laboratory Reimbursement Program (PDF, 28 KB) PDF None English
DPH-42027 F-42027 Wisconsin AIDS/HIV Laboratory Reimbursement Program Agency Enrollment (PDF, 52 KB) PDF None English
DPH-42029 F-42029 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine (PDF, 34 KB) PDF None English
DPH-42029H F-42029H Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine - Hmong (PDF, 28 KB) PDF None Hmong
DPH-42029S F-42029S Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) and/or Varicella Vaccine - Spanish (PDF, 97 KB) PDF None Spanish
DPH-42030 F-42030 Authorization to Receive Tetanus-Diphtheria-Accellular Pertussis (Tdap) Vaccine (PDF, 30 KB) PDF None English
DPH-42030H F-42030H Authorization To Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine - Hmong (PDF, 33 KB) PDF None Hmong
DPH-42030S F-42030S Authorization To Receive Tetanus-Diphtheria-Acellular Pertussis (Tdap) Vaccine - Spanish (PDF, 91 KB) PDF None Spanish
DPH-43005 F-43005 Applicant Physician Assurance for J-1 Visa Waiver Applications (PDF, 897 KB) PDF None English
DPH-43006 F-43006 Health Care Facility Assurance for J-1 Visa Waiver Applications (PDF, 653 KB) PDF None English
DPH F-43009 Diabetes Emergency Action Plan (PDF, 122 KB) PDF none English
DPH F-43013 Diabetes Medical Management Plan (PDF, 587 KB) PDF NONE English
DPH-43015 F-43015 Cardiovascular / Lipid Consultation Record (PDF, 84 KB) PDF None English
DPH-43016 F-43016 Prevent Heart Disease & Stroke Wallet Card Paper Form Center English
DPH F-43020 Wisconsin Diabetes Strategic Plan Endorsement (PDF, 80 KB) PDF None English
DPH F-43020 Wisconsin Diabetes Strategic Plan Endorsement Word None English
DPH-43021 F-43021 Wisconsin Well Woman Program Multiple Sclerosis (MS) Report and Referral Paper Program English
DPH-43023 F-43023 Wisconsin Organ and Tissue Recovery and Assessment (ORGAN - SPECIFIC) (PDF, 291 KB) PDF None English
DPH-43024 F-43024 Wisconsin Organ and Tissue Recovery and Assessment (TISSUE - SPECIFIC) (PDF, 200 KB) PDF None English
DPH-43025 F-43025 Document of Anatomical Gift Authorization for Organ and Tissue Donation (PDF, 261 KB) PDF None English
DPH-43025 F-43025S Document of Anatomical Gift Authorization for Organ and Tissue Donation (PDF, 376 KB) PDF None Spanish
DPH F-43026 Wisconsin Donor Registry Recovery Organization User Access Request (PDF, 38 KB) PDF None English
DPH F-43026 Wisconsin Donor Registry Recovery Organization User Access Request Word None English
DPH-04001 F-44001 Legal Notice (Required Immunizations for Admission to Wisconsin Schools) (PDF, 38 KB) PDF None English
DPH-04001H F-44001H Legal Notice (Required Immunizations for Admission to Wisconsin Schools - Hmong (PDF, 29 KB) PDF None Hmong
DPH-04001S F-44001S Legal Notice (Required Immunizations for Admission to Wisconsin Schools) - Spanish (PDF, 152, KB) PDF None Spanish
DPH-44002 F-44002 Asbestos Certification Application - Company (PDF, 104 KB) PDF None English
DPH-44003 F-44003 Certification Application - Individual Lead-Based Paint Activities and Investigations - Note:  Information and Instructions are attached (PDF, 69 KB) PDF None English
DPH-44005 F-44005 Visual Inspection of Registered Lead-Safe Property (PDF, 15 KB) PDF None English
DPH-44010 F-44010 Lead-Free / Lead-Safe Property Registry, Training Course, Class and Roster Database Access Application (PDF, 16 KB) PDF None English
DPH-44011 F-44011 Application for Registration of Lead-Free or Lead-Safe Property (PDF, 52 KB) PDF None English
DPH-44012 F-44012 Notification of Lead-Based Paint Activity (PDF, 31 KB) PDF None English
DPH-44013 F-44013 Lead-Based Paint (LBP) Investigation Summary Report (PDF, 218 KB) PDF None English
DPH-44014 F-44014 Lead-Free Inspection Affidavit of Property Owner (PDF, 119 KB) PDF None English
DPH-44015 F-44015 Lead Abatement Worker - General Supervision Qualification Affidavit (PDF, 19 KB) PDF None English
DPH-44016 F-44016 Asbestos Occupant Protection Plan (PDF, 32 KB) PDF None English
DPH-44017 F-44017 Asbestos Certification Application - Individual (PDF, 33 KB) PDF None English
DPH-44017S F-44017S Asbestos Certification Application - Individual - Spanish (PDF, 25 KB) PDF None Spanish
DPH-44018 F-44018 Request for Repairs (PDF, 27 KB) PDF None English
DPH-04024A F-44024A WIC Prescriptions / Clinical Data Pregnant, Breastfeeding and Non-Breastfeeding Postpartum Women (PDF, 30 KB) PDF None English
DPH-04024B F-44024B WIC Prescriptions / Clinical Data Children (PDF, 35 KB) PDF None English
DPH F-44024D WIC Formula and Medical Nutritional Prescriptions / Clinical Data Infants (PDF, 51 KB) PDF None English
DPH-44029 F-44029 Credit Card Payment (PDF, 66 KB) PDF None English
DPH-44029S F-44029S Credit Card Payment - Spanish (PDF, 28 KB) PDF None Spanish
DPH F-44063 Lead (Pb) Principal Instructor Application (PDF, 50 KB) PDF None English
DPH-04089 F-44089 Wisconsin WIC Checks Accepted Here - Stickers Paper Form Center English
DPH-04118 F-44118 Instructions For WIC Vendor Application Word Program English
DPH-04118A F-44118A Instructions For WIC Vendor Application Word Program English
DPH-04125 F-44125 Antituberculosis Therapy Program - Follow-up on Therapy (PDF, 47 KB) PDF None English
DPH-04126 F-44126 Antituberculosis Therapy Program Medication Refill Request (PDF, 40 KB) PDF None English
DPH-04151 F-44151 Acute and Communicable Disease Case Report (PDF, 149 KB) PDF Form Center English
DPH-04151 F-44151 Acute and Communicable Disease Case Report Word Form Center English
DPH-04158 F-44158 WIC Application Brochure/Postcard Paper Form Center English
DPH-04158H F-44158H WIC Application Brochure/Postcard - Spanish Paper Form Center Hmong
DPH-04158S F-44158S WIC Application Brochure/Postcard - Spanish Paper Form Center Spanish
DPH-04160A F-44160A WIC Plastic Cover for WIC ID Folder Paper Form Center English
DPH-04160L F-44160L WIC ID Folder Paper Form Center English
DPH-04160LS F-44160LS WIC ID Folder - Spanish Paper Form Center Spanish
DPH-04161 F-44161 WIC Rights and Responsibilities (PDF, 35 KB) PDF Form Center English
DPH-04161H F-44161H WIC Rights and Responsibilities - Hmong (PDF, 30 KB) PDF Form Center Hmong
DPH-04161S F-44161S WIC Rights and Responsibilities - Spanish (PDF, 42 KB) PDF Form Center Spanish
DPH-04192 F-44192 Day Care Immunization Record (PDF, 553 KB) PDF Form Center English
DPH-04192S F-44192S Registro de Inmunizaciones para Guardería Infantil (Day Care Immunization Record) (PDF, 468 KB) PDF None Spanish
DPH-04212 F-44212 School Report to the District Attorney (PDF, 14 KB) PDF Program English
DPH-04236 F-44236 Pertussis Case Report (PDF, 292 KB) PDF None English
DPH-04243 F-44243 Sexually Transmitted Diseases Laboratory & Morbidity Epidemiologic Case Report Word Form Center English
DPH-04257 F-44257 Wisconsin Immunization Record Card Paper Form Center English
DPH-04292 F-44292 VIP Immunization Record 6 X 4 Paper Form Center English
DPH-04322 F-44322 Vendor / Participant Complaint Women, Infant, and Children (WIC) (PDF, 88 KB) PDF None English
DPH-04323 F-44323 WIC Stock Price Survey - Formula and Liquid Nutrition Products(PDF, 15 KB) PDF None English
DPH-04324 F-44324 Vendor Site Visit Paper Program English
DPH F-44444 WIC Vendor Supply Request Word None English
DPH-04614AB F-44614A AIDS / HIV Health Insurance Premium Subsidy Program and AIDS / HIV Drug Assistance Program - Initial Application Part A - Applicant (PDF, 2418 KB) PDF None English
DPH-04614I F-44614I AIDS / HIV Health Insurance Premium Subsidy Program and AIDS / HIV Drug Assistance Program - Application Instructions (PDF, 38 KB) PDF None English
DPH-04614IS F-44614IS AIDS / HIV Health Insurance and Drug Program Application Instructions - Spanish (PDF, 38 KB) PDF None Spanish
DPH-04621 F-44621 Formula and Liquid Nutrition Products WIC Stock Price Survey, F-44621 (PDF, 25 KB) PDF None English
DPH-04702 F-44702 Vaccine Administration Record (PDF, 41 KB) PDF Form Center English
DPH-04702S F-44702S Vaccine Administration Record - Spanish (PDF, 46 KB) PDF Form Center Spanish
DPH-04727 F-44727 WIC Vendor Training Proof Paper Form Center English
DPH-04746 F-44746 FMNP - Site Observation Worksheet (PDF, 15 KB) PDF None English
DPH-04750 F-44750 Inspection Report - Supplement (PDF, 38 KB) PDF Form Center English
DPH-04755 F-44755 WIC Farmers' Market Nutrition Program Word Program English
DPH 4756 F-44756 Wisconsin Tuberculosis Record Card Paper FormsCenter English
DPH 4756H F-44756H Wisconsin Tuberculosis Record Card - Hmong Paper FormsCenter Hmong
DPH 4756S F-44756S Wisconsin Tuberculosis Record Card - Spanish Paper FormsCenter Spanish
DPH-04757 F-44757 WIC Farmer's Market Contract For Farmers Paper Program English
DPH-04763 F-44763 Emergency Care - Do Not Resuscitate Order (DNR) Paper Program English
DPH-04764 F-44764 Bracelet Inserts Paper Program English
DPH-04771A F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels* (PDF, 28 KB) PDF None English
DPH-04771A F-44771A Nursing Case Management Report Case Management of Children with Elevated Blood Lead Levels* Word None English
DPH-04771B F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels (PDF, 558 KB) PDF None English
DPH-04771B F-44771B Nursing Case Closure Report / Case Management of Children with Elevated Blood Lead Levels Word None English
DPH-04771C F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels (PDF, 242 KB) PDF None English
DPH-04771C F-44771C Property Investigation Report / Case Management of Children with Elevated Blood Lead Levels Word None English
DPH-04771D F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels (PDF, 145 KB) PDF None English
DPH-04771D F-44771D Property Investigation Closure Report / Case Management of Children with Elevated Blood Lead Levels Word None English
DPH-04800 F-44800 Farmers Market Nutrition Program (FMNP) - Application for Farmers' Market Managers (PDF, 36 KB) PDF None English
DPH-04817 F-44817 Order To Cease Operation Paper Program English
DPH-04818 F-44818 Wisconsin Well Woman Program (How to order form) (PDF, 390 KB) PDF None English
DPH-04819 F-44819 FMNP - Application for Farmstands (PDF, 28 KB) PDF None English
DPH-04824 F-44824 Wisconsin Day Care Assessment Paper Program English
DPH-04828 F-44828 Make Your Smile Count - Oral Screening Paper Form Center English
DPH-45002A F-45002A Restaurant/Retail Food Service Inspection Report Paper Form Center English
DPH-45002B F-45002B Restaurant/Retail Food Service Inspection Report Page 2 Paper Form Center English
DPH-45002C F-45002C Restaurant/Retail Food Service Inspection Report Page 3 Paper Form Center English
DPH-45003 F-45003 Occupational Exposure Record Per Monitoring Period (PDF, 89 KB) PDF None English
DPH-45004 F-45004 Temporary Restaurant Inspection Report Paper Form Center English
DPH-45006 F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gages or XRF Devices (PDF, 44 KB) PDF None English
DPH-45006 F-45006 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Portable Gauges or XRF Devices Word None English
DPH-45007 F-45007 Certificate of Disposition of Materials (PDF, 17 KB) PDF None English
DPH-45007 F-45007 Certificate of Disposition of Materials Word None English
DPH-45008 F-45008 Application for Radioactive Material License for Medical Use (PDF, 132 KB) PDF None English
DPH-45008 F-45008 Application for Radioactive Material License for Medical Use Word None English
DPH-45009 F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices (PDF, 40 KB) PDF None English
DPH-45009 F-45009 Application for Radioactive Material License Authorizing the Use of Sealed Sources in Fixed Gauge Devices Word None English
DPH-45010A F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) (PDF, 299 KB) PDF None English
DPH-45010A F-45010A Training, Experience and Preceptor Attestation - A (Radiation Safety Officer For Medical Use) Word None English
DPH-45010B F-45010B Training, Experience and Preceptor Attestation - B (Authorized User -Written Directive Not Required) (PDF, 1 MB) PDF None English
DPH-45010B F-45010B Training, Experience and Preceptor Attestation - B (Authorized User -Written Directive Not Required) Word None English
DPH-45010C F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) (PDF, 179 KB) PDF None English
DPH-45010C F-45010C Training, Experience and Preceptor Attestation - C (Unsealed Radioactive Material Requiring A Written Directive) Word None English
DPH-45010D F-45010D Training Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) (PDF, 100 KB) PDF None English
DPH-45010D F-45010D Training Experience and Preceptor Attestation - D (Authorized User For Manual Brachytherapy Sources) Word None English
DPH-45010E F-45010E Training, Experience and Preceptor Attestation - E (Authorized User Of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units) (PDF, 69 KB) PDF None English
DPH-45010E F-45010E Training, Experience and Preceptor Attestation - E (Authorized User of Remote Afterloader, Teletherapy Or Gamma Stereotactic Radiosurgery Units) Word None English
DPH-45010F F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) (PDF, 45 KB) PDF None English
DPH-45010F F-45010F Training, Experience and Preceptor Attestation - F (Authorized Nuclear Pharmacist) Word None English
DPH-45010G F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) (PDF, 54 KB) PDF None English
DPH-45010G F-45010G Training, Experience and Preceptor Attestation - G (Authorized Medical Physicist) Word None English
DPH-45011 F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License (PDF, 21 KB) PDF None English
DPH-45011 F-45011 Certificate - In Vitro Testing with Radioactive Material Under General License Word None English
DPH-45012 F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy (PDF, 64 KB) PDF None English
DPH-45012 F-45012 Application for a Radioactive Material License for a Commercial Radiopharmacy Word None English
DPH-45013 F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography (PDF, 52 KB) PDF None English
DPH-45013 F-45013 Application for a Radioactive Material License Authorizing the Use of Industrial Radiography Word None English
DPH-45014 F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators (PDF, 29 KB) PDF None English
DPH-45014 F-45014 Application for Radioactive Material License Authorizing the Use of Self Shielded Irradiators Word None English
DPH-45015 F-45015 Application for Radioactive Material License for Broad Scope (PDF, 33 KB) PDF None English
DPH-45015 F-45015 Application for Radioactive Material License for Broad Scope Word None English
DPH-45016 F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope (PDF, 47 KB) PDF None English
DPH-45016 F-45016 Application for a Radioactive Material License for Academic, Research and Development and Other Licenses of Limited Scope Word None English
DPH-45017 F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources (PDF, 127 KB) PDF None English
DPH-45017 F-45017 Application for Radioactive Material License Authorizing the Use of Sealed Sources Word None English
DPH-45019 F-45019 Reciprocity Privileges Checklist (PDF, 92 KB) PDF None English
DPH-45020 F-45020 Cumulative Occupational Exposure History (PDF, 149 KB) PDF None English
DPH F-45021 Generally Licensed Device Inspection by Mail (PDF, 20 KB) PDF None English
DPH F-45021 Generally Licensed Device Inspection by Mail Word None English
DPH-45022 F-45022 Application for Material License (PDF, 15 KB) PDF None English
DPH-45022 F-45022 Application for Material License Word None English
DPH-45023 F-45023 Certificate Use of Depleted Uranium under General License (PDF, 308 KB) PDF None English
DPH-45025 F-45025 Patient Questionnaire Paper Program English
DPH-45029 F-45029 School Food Safety Program Inspection Report Paper Form Center English
DPH-45029I F-45029i Instructions For School Food Safety Plan Paper Form Center English
DPH-45030 F-45030 Inspection Narrative Paper Form Center English
DPH-45031 F-45031 Waterslide Inspection Report Paper Form Center English
DPH-45032 F-45032 License, Permit or Registration - Radiation Only Paper Program English
DPH-45036 F-45036 Swimming Pool and Water Attraction Death, Injury and Ilness Report (PDF, 27 KB) PDF Program English
DPH-45038 F-45038 Wisconsin Mercury Exposure Study Paper Program English
DPH F-45039 Campground Plan Approval Application (PDF, 251 KB) PDF None English
DPH-45040 F-45040 Vending Machine Information Record (PDF, 26 KB) PDF None English
DPH-45040 F-45040 Vending Machine Information Record Word None English
DPH-07009 F-47009 Hotel / Motel or Tourist Rooming House Inspection Report Paper Program English
DPH-07013 F-47013 State of Wisconsin Permit Application Word None English
DPH-07014 F-47014 Application/Permits For Vending Machine Operator - Commissary and Machines Word None English
DPH-07015 F-47015 Vending Inspection Report Paper Program English
DPH-07018 F-47018 State of Wisconsin Permit Application to Operate a Mobile Restaurant / Mobile Service Base Word Form Center English
DPH-07020 F-47020 Sink Requirements Paper Program English
DPH-07029 F-47029 Monthly Swimming Pool Operation Report (PDF, 86 KB) PDF None English
DPH-07097 F-47097 Application for Registration of Ionizing Radiation Sources (PDF, 29 KB) PDF None English
DPH-07119 F-47119 Ambulance Run Report (PDF, 110 KB) PDF Program English
DPH-07125 F-47125 Emergency Medical Technician - Intermediate Training Permit Application (PDF, 233 KB) PDF None English
DPH-07128 F-47128 Emergency Medical Technician - Basic Training Permit Application (PDF, 711 KB) PDF None English
DPH-07141 F-47141 Emergency Medical Technician-Paramedic Training Permit Application (PDF, 160 KB) PDF None English
DPH-07181 F-47181 First Responder Certification Card System None English
DPH-07198 F-47198 Noise Exposure Sampling Sheet Paper Program English
DPH-07204 F-47204 Hazard Summary Form Paper Program English
DPH-07205 F-47205 Swimming Pool Inspection Report (PDF, 929 KB) PDF Form Center English
DPH-07206 F-47206 Campground Inspection Report Paper Form Center English
DPH-07208 F-47208 Recreational / Educaional Camp Inspection Report Paper Form Center English
DPH-07208A F-47208A Additional Page for Recreational Sanitation Paper Form Center English
DPH-07217 F-47217 Bed and Breakfast Inspection Report (PDF, 22 KB) PDF Form Center English
DPH-07219 F-47219 Agent Change Sheet Paper Program English
DPH-07222 F-47222 Summary Suspension Paper Program English
DPH-07223A F-47223A Temporary Or Final Order Tag Paper Program English
DPH-07225 F-47225 Report of Enforcement Methods (Part 1) Paper Program English
DPH-07226 F-47226 Report of Enforcement Methods (Part II) Paper Program English
DPH-07228 F-47228 Report of Enforcement Methods Paper Program English
DPH-07236 F-47236 Operations and Maintenance Certificate Paper Program English
DPH-07242 F-47242 Asbestos Certification Application Paper Program English
DPH-07247 F-47247 Ambulance Attendant License/Permit Renew System None English
DPH-07255 F-47255 Emergency Medical Services Funding Assistance Program Application (State Fiscal Year 2014) Word None English
DPH-07257 F-47257 Program Expenditure Report - Emergency Medical Service Funding Assistance For Ambulance Service Providers Word None English
DPH-07300 F-47300 Ambulance Run Report (page 3) Skills /  Extended Comments (PDF, 55 KB) PDF Program English
DPH-07337 F-47337 Application for Registration of Tanning Devices (PDF, 117 KB) PDF None English
DPH-07346 F-47346 Application for Certified Food Manager (PDF, 11 KB) PDF None English
DPH-07453 F-47453 Application for Tattooist / Body Piercer (PDF, 47 KB) PDF None English
DPH-07454 F-47454 Tattoo and Body Piercing Inspection Report (PDF, 2.9 MB) PDF Form Center English
DPH-07460 F-47460 Application for Recertification of Food Manager (PDF, 15 KB) PDF None English
DPH-07461A F-47461A Label-Wash Paper Program English
DPH-07461B F-47461B Label-Rinse Paper Program English
DPH-07461C F-47461C Label-Sanatize Paper Program English
DPH-07461D F-47461D Label-Prewash Paper Program English
DPH F-47463 Emergency Medical Service (EMS) Provider Application and Operational Plan Word None english
DPH-07463A F-47463A First Responder Operational Plan Components (PDF, 19 KB) PDF None English
DPH-07463B F-47463B Emergency Medical Techician (EMT) - Basic Operational Plan Components (PDF, 26 KB) PDF None English
DPH-07463C F-47463C Emergency Medical Techician (EMT) - Intermediate Technician Operational Plan Components (PDF, 721 KB) PDF None English
DPH-07463D F-47463D Emergency Medical Techician (EMT) - Intermediate Operational Plan Components (PDF, 26 KB) PDF None English
DPH-07463E F-47463E Emergency Medical Technician (EMT) - Paramedic Operational Plan Components (PDF, 27 KB) PDF None English
DPH-07464 F-47464 Emergency Medical Technician - Basic IV Training Permit Application (PDF, 160 KB) PDF None English
DPH-07470 F-47470 Change of EMS Medical Director (PDF, 65 KB) PDF None English
DPH-07470 F-47470 Change of EMS Medical Director Word None English
DPH-07471 F-47471 Emergency Medical Technician Verification of Licensure System None English
DPH-07472 F-47472 Emergency Medical Techician (EMT) License / First Responder Certification Renewal Application System None English
DPH-07477 F-47477 First Responder / Emergency Medical Technician Certificate / License System None English
DPH-07478 F-47478 First Responder / Emergency Medical Technician Application Electronic Addition to a Roster System None English
DPH-07479 F-47479 Trauma Care Facility Classification Application (PDF, 2.1 MB) PDF None English
DPH-07479 F-47479 Trauma Care Facility Classification Application Word None English
DPH-07480 F-47480 Level III and IV Hospital Assessment and Classification Criteria (PDF, 62 KB) PDF None English
DPH-07480 F-47480 Level III and IV Hospital Assessment and Classification Criteria Word None English
DPH-07482 F-47482 Emergency Medical Service Training Center Certification Application (PDF, 84 KB) PDF None English
DPH-07484 F-47484 Pre-Review Questionnaire and Application Checklist Word None English
DPH-07489 F-47489 Emergency Medical Services (EMS) Patient Care Worksheet (PDF, 620 KB) PDF None English
DPH-09027 F-49027 Environmental Protection Agency (EPA) Official Water Lab Survey Paper Program English
DPH-09357 F-49357 Personal Diabetes Care Record (PDF, 152 KB) PDF Form Center English
DPH-09357S F-49357S Personal Diabetes Care Record - Spanish (PDF, 102 KB) PDF Form Center Spanish