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.
- F-62333 Plan Approval Application – Hospitals and Nursing Homes (Word)
- F-62496 Plan Approval Application – Free-Standing CBRF (Word) – Use this form only if the facility is NOT attached to, or integrated into, another health care provider as defined in Wis. States, Chp. 58.
- F-62457 Permission to Start Construction Request (Word) – Permission to start can be required for footing and foundation work only. Contact the local municipality for specific permitting criteria.
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.
- F-62495 Compliance Statement (Word) – Required prior to the initial occupancy of a new building or addition, as well as required prior to the final occupancy of an alteration of an existing building.
- F-62494 Health Care Facility Construction Documentation Checklist (Word)
- F-00016 Wall Closure Inspection Checklist (Word) – Common items inspected prior to enclosing a wall assembly.
- F-00015 Final Occupancy Inspection Checklist (Word) – Common items inspected prior to occupancy.
- F-00014 Ceiling Closure Inspection Checklist (Word) – Common items inspected prior to enclosing a ceiling cavity.
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:
- F-62537 Petition for Building Code Variance (Word) – Complete and submit this form to petition for a variance from the building code.
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.
