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.
- Plan Approval Application – Hospitals and Nursing Homes, F-62333 (Word)
- Plan Approval Application – Free-Standing CBRF, F-62496, (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.
- Permission to Start Construction Request, F-62457 (Word) – Permission to start can be required for footing and foundation work only. Contact the local municipality for specific permitting criteria.
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.
- Compliance Statement, F-62495 (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.
- Health Care Facility Construction Documentation Checklist, F-62494 (Word)
- Wall Closure Inspection Checklist, F00016 (Word) – Common items inspected prior to enclosing a wall assembly.
- Final Occupancy Inspection Checklist, F-00015 (Word) – Common items inspected prior to occupancy.
- Ceiling Closure Inspection Checklist, F-00014 (Word) – Common items inspected prior to enclosing a ceiling cavity.
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:
- Petition for Building Code Variance, F-62537 (Word) – Complete and submit this form to petition for a variance from the building code.
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.
