Hospice - Forms



For questions regarding hospices, you may email the Division of Quality Assurance

The following forms are used throughout the survey process. Surveyors use these forms to evaluate your program during the initial licensing process as well as any future onsite compliance surveys. They are linked here to assist your agency in self assessment and quality improvement.

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, F-62500 (Word) and fax to 608-267-0352. Questions about this process may be directed to the "Fire Authority" at 608-266-8016. Refer to DQA memo 17-003 (PDF) for additional information.

Last Revised: July 5, 2017