Forms Library

Forms produced by the Wisconsin Department of Health Services are available for downloading and printing from this site. If a form is not available electronically, you will be provided instructions for requesting a paper copy. If you are searching for a form number that does not start with the letter "F," just enter the number you have available and you will get a better search result. Example, looking for DDE-2539? Enter "2539" in the Search Forms field below.

The Division of Health Care Access and Accountability (DHCAA) and Division of Long Term Care (DLTC) have combined into the Division of Medicaid Services (DMS). When searching for forms by Division, please use the new acronym.

Assigned Numbersort ascending Title Other Location Language
F-42011 Interjurisdictional Tuberculosis Notification - Follow-up (PDF, 87 KB) English
F-42010 Interjurisdictional Tuberculosis Notification (PDF, 24 KB) English
F-42007 Mail Label 3 X 4 - Immunization Program English
F-42002 Warning: Do Not Unplug Refrigerator - Label English
F-42001 Tuberculosis Suspect Case Data (PDF, 811 KB) English
F-42000 Vaccine Order (PDF, 16 KB) English
F-40335 Pre-School Oral Health Preliminary Exam and Prevention Services (PDF, 439 KB) English
F-40310 Adult Oral Health Screening (PDF, 176 KB) English
F-40309A Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Agreement (PDF, 210 KB) English
F-40309 Wisconsin Emergency Assistance Volunteer Registry (WEAVR) Administrative Access User Security and Confidentiality Policy (PDF, 303 KB) English
F-40303 Early Childhood Caries Prevention Screening (PDF, 117 KB) English
F-40123A Hearing Screening Postcard - English English
F-40117 Abortion Information Provision Certification English
F-40108 Retail Vendor Application Amendment Women, Infant, and Children (WIC) English
F-40104 WIC Retail Vendor Annual Food Sales Survey English
F-40098 Worksite Wellness Kit Survey and Request English
F-40097 Wisconsin Nutrition and Physical Activity Program State Plan Endorsement (PDF, 82 KB) English
F-40096 WIC Program Repayment Agreement English
F-40093 Annual ROSIE User Security and Confidentiality Agreement English
F-40092 Physical Activity Zone (PDF, 229 KB) English
F-40085 WIC Program Notice of Ineligibility English
F-40076 WIC Income Statement English
F-40075 Pedometer Walking Program (PDF, 83 KB) English
F-40074 Annual Physical Activity Record (PDF, 27 KB) English
F-40073 Monthly Physical Activity Sheet (PDF, 61 KB) English
F-40072 8 Week Activity Log (PDF, 19 KB) English
F-40071 Children's Physical Activity Chart (PDF, 18 KB) English
F-40065 Storage Facility Review Monitoring Report English
F-40064 Transfer of The Emergency Food Assistance Program (TEFAP) Commodities between EFO's English
F-40063 The Emergency Food Assistance Program (TEFAP) Commodities Complaint English
F-40062 The Emergency Food Assistance Program TEFAP and CSFP Commodity Loss Report English
F-40060 The Emergency Food Assistance Program Commodities Inventory Report English
F-40059 The Emergency Food Assistance Program (TEFAP) Eligibility Certification English
F-40058 Verification of Transfer of USDA Commodities English
F-40057 Authorization and Permission For Release of Information to Wisconsin Birth Defects Prevention and Surveillance System and Early Childhood Program (PDF, 32 KB) English
F-40056 Wisconsin Birth Defects Registry (WBDR) User Security and Confidentiality Agreement English
F-40054 Confidential Birth Defects Registry Report English
F-40053 Farmers' Market Nutrition Program (FMNP) - Verification of Participation in Farmer Training English
F-40044 Participant Agreement, Rights & Responsibilities English
F-40041 Certification & Food Package Pick-Up English
F-40040 Envelope - No. 9 Vendor and Integrity Unit Address English
F-40036 Wisconsin Women, Infant, and Children (WIC) Program Vendor Agreement English
F-40034 Wisconsin WIC Program Retail Vendor Initial Authorization Application and Instructions for Completing English
F-40028 Participant Determination Letter English
F-40019 Affirmation of Identity, Residency, and/or Income English
F-29323 Hardship Policy / Hidden Asset Policy (PDF, 17 KB) English
F-29322 Uniform Cost Sharing Plan - COP Cost-Share Worksheet 3 English
F-29321 COP Cost-Share Worksheet #2 English
F-29320 COP Cost-Share Worksheet #1 Instructions English
F-29319 COP Cost-Share Worksheet English


Last Revised: July 28, 2017