Nursing Homes: Forms

Fire Reporting

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).

All fires are to be reported by completing and submitting the online Health Care Facility Fire Report, F-62500.

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.

Informed Consent for Medications

Informed Consent for Medications F-24277 Series – medication forms for informed consent for psychotropic medications for nursing home residents

PASARR

A Pre-admission Screen and Resident Review (PASARR) Level 1 Screen must be completed prior to admission to a nursing facility admission to determine if a person reasonably is suspected of having a serious mental illness or a developmental disability, which necessitates a PASARR Level II Screen prior to admission unless a short-term exemption, per Wisconsin PASARR policies, is appropriate

Pre-admission Screen and Resident Review (PASARR) Level 1 Screen, F-22191 (Word)

Plan Review

Construction/Remodeling of Health Care Facilities: Plan Review Requirements

Last Revised: August 19, 2019