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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-22539 Request for Waiver of State SSI or Caretaker Supplement Overpayment Recovery or Change in Repayment Rate DMS English 06/2015 PDF No
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH English 07/2016 Word No
F-02068 Request to Establish a Children's COP Risk Reserve DMS English 04/2017 Word No
F-03266 Request to Lower Your FoodShare Overpayment DMS English 02/2024 PDF No
F-03266H Request to Lower Your FoodShare Overpayment, Hmong DMS Hmong 02/2024 PDF No
F-03266S Request to Lower Your FoodShare Overpayment, Spanish DMS Spanish 02/2024 PDF No
F-02603 Request to Not Pay Your Medicaid Purchase Plan Premium for a Short Time Because of a Difficult Situation DMS English 05/2024 PDF No
F-02603H Request to Not Pay Your Medicaid Purchase Plan Premium for a Short Time Because of a Difficult Situation, Hmong DMS Hmong 05/2024 PDF No
F-02603S Request to Not Pay Your Medicaid Purchase Plan Premium for a Short Time Because of a Difficult Situation, Spanish DMS Spanish 05/2024 PDF No
F-19002 Request to Reduce QUEST Card Balance DMS English 08/2023 PDF No
F-01845 Request to Remain on the Wisconsin AIDS Drug Assistance Program and Decline Enrollment in Health Insurance DPH English 10/2016 PDF No
F-01845S Request to Remain on the Wisconsin AIDS Drug Assistance Program and Decline Enrollment in Health Insurance - Spanish DPH Spanish 10/2016 PDF No
F-00977 Research Data Use Agreement - Principal Investigator, Wisconsin Cancer Reporting System (WCRS) DPH English 05/2021 PDF No
F-62373 Resident Evacuation Assessment DQA English 04/2009 Word No
F-62373 Resident Evacuation Assessment DQA English 04/2009 PDF No
F-02282A Resident Relocation Plan DMS English 10/2023 Word No
F-02282 Resident Relocation Roster DMS English 07/2018 Excel No
F-02634C Residential Care Apartment Complex (RCAC) Initial Survey Checklist DQA English 03/2020 Word No
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS English 06/2023 PDF No
F-02766 Residential Substance Use Disorder Treatment for BadgerCare Plus and Medicaid Members DMS English 06/2023 Word No
F-03147 Resilient Wisconsin Help the Helper Training Evaluation DCTS English 04/2023 HTML No
F-40108 Retail Vendor Application Amendment Wisconsin Women, Infant, and Children (WIC) DPH English 03/2024 PDF No
F-01999A Retired Senior Volunteer Program: State Match Funding Application DPH English 09/2019 Word No
F-01800 Retroactive Overtime To Be Paid DMS English 01/2019 Word No
F-21189 Rights of Detention DCTS English 05/2017 Word No
F-21189S Rights of Detention, Spanish DCTS Spanish 05/2017 Word No
F-62601 Rights of Home Health Agency Patients DQA English 05/2020 PDF No
F-62601S Rights of Home Health Agency Patients, Spanish DQA Spanish 05/2020 PDF No
F-01558 Risk Agreement - IRIS Program DMS English 09/2023 Word No
F-00945 Risk Identification and Assessment Worksheet and Purchase of Service Audit Waiver Request OS English 11/2023 HTML No
F-00945i Risk Identification and Assessment Worksheet and Purchase of Service Audit Waiver Request Instructions OS English 11/2023 PDF No
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS English 04/2009 PDF No
F-11025 Rural Health Clinic Commercial Insurance-Primary / Medicaid-Secondary Encounters Submitted to Medicaid HMOs DMS English 04/2009 Word No
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS English 04/2009 PDF No
F-11026 Rural Health Clinic Medicaid-Primary Encounters Submitted to Medicaid HMOs DMS English 04/2009 Word No
F-11081 Rural Health Clinic Provider Staff Encounters DMS English 10/2016 Excel No
F-11027 Rural Health Clinic Quarterly Cost Report DMS English 10/2016 Excel No
F-11022 Rural Health Clinic Statistical Data DMS English 10/2016 PDF No
F-11022 Rural Health Clinic Statistical Data DMS English 10/2016 Word No
F-03081 Safe and Healthy Home Assessment DPH English 08/2022 PDF No
F-03081 Safe and Healthy Home Assessment DPH English 12/2022 Excel No
F-02828 School P-EBT Verification Letter Template DMS English 06/2021 Word No
F-04002 School Report to Local Health Department, 2024-2025 DPH English 02/2024 PDF No
F-44212 School Report to the District Attorney DPH English 07/2016 PDF No
F-02875 Self-Care Assessment DPH English 09/2021 Word No
F-00107 Self-Employment Income Report DMS English 06/2019 PDF No
F-00107CM Self-Employment Income Report, Chinese Mandarin DMS Chinese Mandarin 06/2019 PDF No
F-00107H Self-Employment Income Report, Hmong DMS Hmong 06/2019 PDF No
F-00107S Self-Employment Income Report, Spanish DMS Spanish 06/2019 PDF No
F-00219 Self-Employment Income Report: Farm Business DMS English 06/2019 PDF No
Last revised December 8, 2023