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Data Collection (Forms) Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions.

When you are searching for a form, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-62645C Drug Repository Program: Destruction Record DQA English 05/2020 Word No
F-62645B Drug Repository Program: Donation Record DQA English 05/2020 Word No
F-62645 Drug Repository Program: Recipient Record DQA English 05/2020 Word No
F-62645 Drug Repository Program: Recipient Record DQA English 05/2020 PDF No
F-62645A Drug Repository Program: Transfer Record DQA English 05/2020 Word No
F-02891 Durable Medical Equipment Home Accessibility Report DMS English 08/2022 Word No
F-02891 Durable Medical Equipment Home Accessibility Report DMS English 08/2022 PDF No
F-40303 Early Childhood Caries Prevention Screening DPH English 10/2003 PDF No
F-00989F Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP) DMS English 02/2017 Word No
F-00989FS Early Intervention Team Report / Wisconsin Early Intervention Eligibility Determination (IFSP), Spanish DMS Spanish 02/2017 Word No
F-01411 Education - Medication Summary - Part B DPH English 10/2017 Word No
F-01410 Education Summary DPH English 07/2022 PDF No
F-00079 Effective for use before 07/01/2019: Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil DMS English 01/2019 PDF No
F-00079 Effective for use before 07/01/2019: Prior Authorization/Preferred Drug List (PA/PDL) for Armodafinil and Modafinil Instructions DMS English 01/2019 PDF No
F-21150 Elder Adults/Adults-at-Risk Agency Conflict of Interest Notification and Transfer of Investigation Powers DPH English 07/2016 Word No
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS English 04/2023 Word No
F-02717 Electronic Visit Verification (EVV) Live-in Worker Identification DMS English 04/2023 PDF No
F-02717H Electronic Visit Verification (EVV) Live-in Worker Identification, Hmong DMS Hmong 04/2023 Word No
F-02717H Electronic Visit Verification (EVV) Live-in Worker Identification, Hmong DMS Hmong 04/2023 PDF No
F-02717S Electronic Visit Verification (EVV) Live-in Worker Identification, Spanish DMS Spanish 04/2023 Word No
F-02717S Electronic Visit Verification (EVV) Live-in Worker Identification, Spanish DMS Spanish 04/2023 PDF No
F-44763 Emergency Care Do Not Resuscitate Order (DNR) DPH English 11/2022 PDF No
F-44763S Emergency Care Do Not Resuscitate Order (DNR), Spanish DPH Spanish 11/2022 PDF No
F-00646 Emergency Medical Service Training Center Training Permit Eligibility Certification DPH English 09/2019 Word No
F-02570 Emergency Medical Services (EMS) E-Licensing Service Demographic Information DPH English 11/2019 PDF No
F-00567 Emergency Medical Services Complaint DPH English 08/2021 PDF No
F-00567 Emergency Medical Services Complaint DPH English 11/2022 HTML No
F-47255 Emergency Medical Services Program Municipal Signature and Population Verification DPH English 11/2019 PDF No
F-47472 Emergency Medical Technician (EMT) License / First Responder Certification Renewal Application DPH English 11/2009 HTML No
F-47471 Emergency Medical Technician Verification of Licensure DPH English 03/2003 HTML No
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 DQA English 01/2012 PDF No
F-00551 Emergency Mental Health Service Program Initial Certification Application - DHS 34 DQA English 01/2012 Word No
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA English 03/2013 PDF No
F-00571 Emergency Mental Health Service Program Recertification Application - DHS 34 DQA English 03/2013 Word No
F-22559 Employee Training Acknowledgement - Legal Restriction on Tobacco Sales to Minors DPH English 01/2020 PDF No
F-00246 Employer Health Insurance Verification Individual Follow-Up Health Insurance Information DMS English 06/2019 PDF No
F-10146 Employer Verification of Earnings DMS English 02/2022 Word No
F-10146A Employer Verification of Earnings: Proof of Employment DMS English 06/2020 Word No
F-03042 Employer-Sponsored Blood Drives Grant Funding Opportunity: Application DPH English 05/2022 HTML No
F-02871 emPOWER Data Use Evaluation DPH English 09/2021 HTML No
F-00568 EMS Board Sub-Committee Appointment Application DPH English 09/2019 Word No
F-02205 EMS Instructor II Evaluation DPH English 09/2017 Word No
F-47489 EMS Patient Care Worksheet DPH English 08/2015 PDF No
F-00987B EMS Service Operational Plan Advanced Skills Addendum (Advanced) DPH English 05/2015 Word No
F-00987C EMS Service Operational Plan Advanced Skills Addendum (First Responder) DPH English 09/2016 Word No
F-00987A EMS Service Operational Plan Advanced Skills Addendum (Intermediate) DPH English 05/2015 Word No
F-00987D EMS Service Operational Plan Advanced Skills Addendum (Paramedic) DPH English 05/2014 Word No
F-00987 EMS Service Operational Plan, Advanced Skills Addendum (Basic) DPH English 05/2015 Word No
F-47463I EMS Service Provider Level Downgrade Operational Plan Components Checklist DPH English 09/2022 Word No
F-47463H EMS Service Provider Level Upgrade Operational Plan Components Checklist DPH English 09/2022 Word No
Last revised December 8, 2023