For questions regarding community based residential facilities, you may contact the Bureau of Assisted Living, Division of Quality Assurance.
*Asterisks mark fillable PDF forms, select the first field to begin typing. Tab from field to field. You can print the altered document but do not expect to save it with changes.
- F-60287: *CBRF Initial License Application (PDF, 215 KB)
- F-62496: *Free-Standing CBRF Plan Approval Application (PDF, 120 KB)
- F-62548: *Assisted Living Facility Request for Waiver, Approval, Variance or Exception (PDF, 17 KB)
- F-62430: *Community Based Residential Facility - Residents' Rights Complaint Report (PDF, 21 KB)
- F-62372: Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation (PDF, 16 KB)
- F-60795: Fire Inspection Community Based Residential Facility (CBRF) (PDF, 195 KB)
- F-62373: Resident Evacuation Assessment (PDF, 35 KB)
- F-60309: *Self Supervision Evaluation & Waiver Request (PDF, 64 KB)
- F-62370: Significant Change in Health Screening Instrument (PDF, 8 KB)
- F-62369: *Waiver of Hospice or Home Health Services by a Terminally Ill CBRF Resident (PDF, 14 KB)
All fires in a licensed health or residential care facility in Wisconsin must be reported to the Department of Health Services within 72 hours (check specific rule requirements).
- You may use the Fire Report Form (Word, 78 KB) and fax to 608-264-9847. Questions about this process may be directed to the "Fire Authority" at 608-266-0224. Refer to DQA memo 12-013 for additional information.
Construction/Remodeling of Health Care Facilities - Plan Review Requirements (including forms)
Wisconsin Client Rights and Grievance Procedure - includes forms