Community Based
Residential Facilities - Forms
Introduction | Rules_&_Regulations
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For questions regarding community based residential
facilities, you may contact the Bureau
of Assisted
Living, Division of Quality Assurance.
*Asterisks mark fillable PDF forms, select the first field
to begin typing. Tab from field to field. You can print the altered document but
do not expect to save it with changes.
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F-60287: *CBRF Initial License Application
(PDF, 215 KB)
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F-62496: *Free-Standing
CBRF Plan Approval Application (PDF, 120 KB)
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F-62548: *Assisted Living Facility Request for Waiver, Approval, Variance or
Exception
(PDF, 17 KB)
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F-62430: *Community Based Residential Facility - Residents' Rights Complaint
Report
(PDF, 21 KB)
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F-62372: Community
Based Residential Facility (CBRF) Resident Satisfaction Evaluation
(PDF, 16 KB)
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F-60795: Fire
Inspection Community Based Residential Facility (CBRF)
(PDF, 195 KB)
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F-62373: Resident
Evacuation Assessment
(PDF, 35 KB)
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F-60309: *Self
Supervision Evaluation & Waiver Request (PDF,
64 KB)
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F-62370: Significant
Change in Health Screening Instrument
(PDF, 8 KB)
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F-62369: *Waiver
of Hospice or Home Health Services by a Terminally Ill CBRF Resident
(PDF, 14 KB)
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Fire
Report form DQA F-62500 (Word, 78 KB) - Fillable form with
contacts to assist the reporting of fires in a healthcare facility.
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Fire
Watch memorandum DQA 12-013 - Outlines the minimum procedures for
when a required sprinkler or fire alarm system is out of service.
Construction/Remodeling of Health Care Facilities
Plan
Review Requirements (including forms)
Wisconsin
Client Rights and Grievance Procedure - includes forms
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Last Updated: August 21, 2012 |
