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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-44001SO Legal Notice: Required Immunizations for Admission to Wisconsin Schools, Somali DPH Somali 06/2016 PDF No
F-44001S Legal Notice: Required Immunizations for Admission to Wisconsin Schools, Spanish DPH Spanish 06/2016 PDF No
F-01661 Letter - Foster Care Termination, Family DMS English 07/2023 Word No
F-01661A Letter - Foster Care Termination, Youth DMS English 11/2023 Word No
F-05260 Letter of Non-Marriage Application DPH English 02/2024 PDF No
F-05260S Letter of Non-Marriage Application - Spanish DPH Spanish 02/2024 PDF No
F-02607 Letter: 1-2 Bed Adult Family Home Recertification Application DMS English 02/2020 Word No
F-01567A Letter: Request for Assignment of Medical Benefits DMS English 01/2021 Word No
F-02876 Letter: Screen Visit Not Scheduled DMS English 09/2021 Word No
F-02876H Letter: Screen Visit Not Scheduled, Hmong DMS Hmong 09/2021 Word No
F-02876S Letter: Screen Visit Not Scheduled, Spanish DMS Spanish 09/2021 Word No
F-02874 Letter: Screen Visit Scheduled DMS English 09/2021 Word No
F-02874H Letter: Screen Visit Scheduled, Hmong DMS Hmong 09/2021 Word No
F-02874S Letter: Screen Visit Scheduled, Spanish DMS Spanish 09/2021 Word No
F-02663 Letterhead - EVV Personal Identification Number (PIN) DMS English 02/2021 HTML No
F-47484 Level III Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word No
F-47484A Level IV Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word No
F-62019 License Application for Nursing Home, Intermediate Care Facility - Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA English 12/2014 Word No
F-01022 License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS English 02/2017 Excel No
F-00165E Limited English Proficiency (LEP) Customer Data Analysis Chart OLC English 12/2021 Word No
F-02731 Line List: Respiratory Virus Outbreak - Workplace Environment DPH English 10/2020 Excel No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-03036 Local and Tribal Health Department (LTHD) Antigen Test Distribution Program Participation Attestation DPH English 05/2022 PDF No
F-01802A Local Prescriber Naloxone Standing Order for Pharmacists template DPH English 12/2019 Word No
F-01573 Log of Ice Arena Air Quality DPH English 06/2015 Word No
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA English 04/2020 Word No
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA English 04/2020 PDF No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 Word No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 PDF No
F-01567S Long-Term Care Insurance Policy - Assignment of Benefits, Spanish DMS Spanish 12/2018 PDF No
F-03069 LTHD COVID-19 Antigen Test Distribution Program DPH English 04/2023 HTML No
F-02188 Lyme Disease Case Worksheet DPH English 02/2022 PDF No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 Word No
F-12022 Managed Care Program Provider Appeal DMS English 02/2020 PDF No
F-12022A Managed Care Program Provider Appeal Instructions DMS English 02/2020 PDF No
F-02946 Management Evaluation Review (MER) Advocate Survey DMS English 02/2024 HTML No
F-02945 Management Evaluation Review (MER) Income Maintenance (IM) Staff Survey DMS English 02/2024 HTML No
F-00777 MAPT Vendor Related Allocation Formula DMS English 02/2017 Word No
F-01915 Marketplace or Indicator Gap Filling Eligibility Determinations Supplemental Letter DMS English 07/2017 Word No
F-01481 Marriage Record Amendment Request Officiant Affidavit DPH English 04/2015 PDF No
F-02531 Maternal Mortality Review Application DPH English 08/2019 PDF No
F-02655 Maternal Mortality Review Team Community Member Application DPH English 06/2020 PDF No
F-02707 Maternal Mortality Review Team Guest Pledge of Confidentiality DPH English 08/2020 PDF No
F-01803 Maternal Referral / Communication Wisconsin WIC Program DPH English 03/2019 Word No
F-03050 MC4JR Partnership Snapshot DPH English 06/2022 HTML No
F-02747 MCO Approval Request to DHS Performance Improvement Project (PIP) DMS English 11/2022 Word No
F-01590 MCO Letter: Notice of Change in Level of Care DMS English 02/2020 Word No
F-01590AR MCO Letter: Notice of Change in Level of Care, Arabic DMS Arabic 02/2020 Word No
Last revised December 8, 2023