Construction/Remodeling for Health Care Facilities – Forms and Checklists

Plan Approval Application

The following forms are required for submission of a plan review. If you have any questions regarding the forms, you can call the Division of Quality Assurance (DQA), Office of Plan Review and Inspection (OPRI), Plan Intake Coordinator at 608-264-7748.

NOTE: The Department 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

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 following 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

Providers, adult family homes, community based residential facilities, facilities serving people with developmental disabilities, hospitals, nursing homes, and residential care apartment complexes, are required to report all incidents of fire within their facility to DHS using this form:

  • F-62500 Fire Report (Word) – This form is used to report to the Division within 72 hours of the incident, all fires in a hospital, nursing home, facility for the developmentally disabled, community based residential facility and adult family home.
Last Revised: April 10, 2017