Construction/Remodeling for Health Care Facilities: Forms and Checklists

Plan Submittals

Construction plans may be submitted to the Office of Plan Review and Inspection (OPRI) either by mail or an electronic pdf file. Both types of drawings must bear the seal and signature of the representing design professional. Payment for both types of plan submittals will need to be in the form of a check mailed to the plan intake office along with a copy of the plan application. This will ensure the plan review coordinator matches it to the correct construction project.

Note: The Department of Health Services (DHS) is allowed 45 business days to complete a plan review once an application is determined complete. Incomplete applications will not be processed.

Incomplete applications may include:

  • omitted items (plans, application form, money)
  • plan is not signed/sealed
  • incorrect fee
  • missing or incorrect information on the application

Submit health care facility plumbing plans to the Department of Safety and Professional Services (DSPS) for plan review:

Compliance Statement and Checklist

A completed Compliance Statement is required to be submitted to OPRI prior to finale inspection. Checklists are tools to use as a reference list of common items reviewed during a health care construction inspection. Questions relating to required elements of a final occupancy inspection should be directed to your DQA inspector.

Petition for Variance

The Petition for Variance form should be used for applicants who are seeking a variance for an alternative method of compliance to a specific building code requirement:

Fire Report

Licensed adult family homes, community-based residential facilities, facilities serving people with developmental disabilities, hospitals, and nursing homes are required to report within 72 hours, all incidents of fire in their facility by completing and submitting the online Health Care Facility Fire Report, F-62500.

Contact Us

Mail completed forms to:

DHS/Division of Quality Assurance
ATTN: Plan Intake Coordinator
819 N. 6th St., Room 609B
Milwaukee, WI 53203-1606

You may also email to DHSDQAPlanReview@dhs.wisconsin.gov.

If you have questions regarding completion of forms, you may call the Plan Intake Coordinator at 414-227-4085.

Last Revised: July 2, 2019