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Wisconsin Department of Health Services

If You Have Complaints about Wisconsin Health Care

Information about Division of Quality Assurance (DQA)

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Provider Types Regulated by DQA

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DQA Numbered Memos

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WI Adult Programs Caregiver Misconduct Registry

Adult Family Homes - Forms

Introduction | Rules_&_Regulations | Forms | Providers |
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For questions regarding adult family homes, you may contact the Bureau of Assisted Living, Division of Quality Assurance (attention the Bureau of Assisted Living).

The first two items are fillable PDF forms - select the first field to begin typing. Tab from field to field. You can print this document but you cannot save it.

  • F-62548 (PDF, 17 KB): Assisted Living Facility Request for Waiver, Approval, Variance or Exception

  • F-62500 (PDF, 11 KB): Fire Report form - To report fires in a facility.

  • F-62373 (PDF, 35 KB): Resident Evacuation Assessment

  • Fire Report form DQA F-62500 (Word, 78 KB) - Fillable form with contacts to assist the reporting of fires in a healthcare facility.
  • Fire Watch memorandum DQA 12-013 - Outlines the minimum procedures for when a required sprinkler or fire alarm system is out of service.

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Last Updated: August 21, 2012