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 414-227-4085.

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

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:

Mail completed Petition for Building Code Variance to:

OPRI Plan Intake Coordinator
819 N. 6th St., Room 609B
Milwaukee, WI 53203-1606

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:

  • Fire Report, F-62500 (Word) – This form is used to report to DHS 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: February 12, 2018