Division of Quality Assurance Construction/Remodeling
 for
 Health Care Facilities

Forms
(Applications, Permit to Start)
 Petition for Variance
Fire Report

The following forms are required for submission of a plan review. If you have any questions regarding the forms, you can call 608-264-7748 (DQA Plan Intake Coordinator - Madison).

• F-62333 Plan Approval Application
• F-62496 Free-Standing CBRF Plan Approval Application. Use this form only if the facility is NOT attached to, or integrated into, another health care provider as defined in Wis. States, Chp. 58.
• F-62457 Permission to Start Construction Request

NOTE: The Department is allowed 45 business days to complete a plan review once an application is determined complete. Incomplete applications will not be processed.

Common submittal errors include:

• omitted items (plans, application form, money)
• plan is not signed/sealed
• incorrect fee
• missing or incorrect information on the application

Submittal process:

1. Compile plans, professionally stamped and signed
2. Verify the application form is complete and attached a check or money order

3. Mail or ship to the appropriate Intake Office:

4. Allow 10 business days for processing

5. DQA Inspector will contact the applicant with the results of the review via letter

The following Petition for Variance form should be used for applicants who are seeking a variance for an alternative method of compliance to a specific building code requirement:

• F-62537 Petition for Building Code Variance. Complete and submit this form to petition for a variance from the building code or for approval of an alternative design that is not in strict conformance with the letter of the code but meets the intent of the code.

Providers, adult family homes, community based residential facilities, facilities serving people with developmental disabilities, hospitals, nursing homes, and residential care apartment complexes, are required to report all incidents of fire within their facility to DHS using this form:

• F-62500 Fire Report. This form is used to report to the Division within 72 hours of the incident, all fires in a hospital, nursing home, facility for the developmentally disabled, community based residential facility and adult family home.

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