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Data Collection (Forms) Library

Forms produced by the Wisconsin Department of Health Services are available electronically and/or for paper order. Review the "Available to Order" column below to ensure availability in paper format. If the document is available to order in a paper version, there will be a "Yes" with a link to ordering instructions.

When you are searching for a form, enter the number or a portion of the title in the search box below.

Assigned Number Title Division Language Release Date File Type Available to Order
F-02876 Letter: Screen Visit Not Scheduled DMS English 09/2021 Word No
F-02876H Letter: Screen Visit Not Scheduled, Hmong DMS Hmong 09/2021 Word No
F-02876S Letter: Screen Visit Not Scheduled, Spanish DMS Spanish 09/2021 Word No
F-02874 Letter: Screen Visit Scheduled DMS English 09/2021 Word No
F-02874H Letter: Screen Visit Scheduled, Hmong DMS Hmong 09/2021 Word No
F-02874S Letter: Screen Visit Scheduled, Spanish DMS Spanish 09/2021 Word No
F-02663 Letterhead - EVV Personal Identification Number (PIN) DMS English 02/2021 HTML No
F-47484 Level III Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word No
F-47484A Level IV Pre-Review Questionnaire (PRQ) DPH English 07/2023 Word No
F-62019 License Application for Nursing Home, Intermediate Care Facility - Individuals with Intellectual Disabilities (ICF-IID), or Institute for Mental Disease (IMD) DQA English 12/2014 Word No
F-01022 License Application Nursing Home, Facility for Developmentally Disabled, Institute for Mental Disease DMS English 02/2017 Excel No
F-00165E Limited English Proficiency (LEP) Customer Data Analysis Chart OLC English 12/2021 Word No
F-02731 Line List: Respiratory Virus Outbreak - Workplace Environment DPH English 10/2020 Excel No
F-16104 Local Agency Customer Feedback DMS English 10/2017 PDF Yes
F-16104H Local Agency Customer Feedback, Hmong DMS Hmong 10/2017 PDF No
F-16104S Local Agency Customer Feedback, Spanish DMS Spanish 10/2017 PDF Yes
F-03036 Local and Tribal Health Department (LTHD) Antigen Test Distribution Program Participation Attestation DPH English 05/2022 PDF No
F-01802A Local Prescriber Naloxone Standing Order for Pharmacists template DPH English 12/2019 Word No
F-01573 Log of Ice Arena Air Quality DPH English 06/2015 Word No
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 09/2024 Word No
F-03246 Long-Term Care (LTC) Waiver Consumer Education and Training Attestation DMS English 09/2024 PDF No
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 09/2024 PDF No
F-03243 Long-Term Care (LTC) Waiver Daily Living Skills Attestation DMS English 09/2024 Word No
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 09/2024 Word No
F-03244 Long-Term Care (LTC) Waiver Financial Management Attestation DMS English 09/2024 PDF No
F-03245 Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 09/2024 PDF No
F-03245 Long-Term Care (LTC) Waiver Home Modification Attestation DMS English 09/2024 Word No
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 09/2024 Word No
F-03234 Long-Term Care (LTC) Waiver Housing Counseling Attestation DMS English 09/2024 PDF No
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 09/2024 Word No
F-03235 Long-Term Care (LTC) Waiver Incidental Personal Care Attestation DMS English 09/2024 PDF No
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation DMS English 09/2024 PDF No
F-03236 Long-Term Care (LTC) Waiver Prevocational Attestation DMS English 09/2024 Word No
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation DMS English 09/2024 PDF No
F-03237 Long-Term Care (LTC) Waiver Support Broker Attestation DMS English 09/2024 Word No
F-03238 Long-Term Care (LTC) Waiver Supported Employment Attestation DMS English 09/2024 Word No
F-03238 Long-Term Care (LTC) Waiver Supported Employment Attestation DMS English 09/2024 PDF No
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation DMS English 09/2024 Word No
F-03239 Long-Term Care (LTC) Waiver Supportive Home Care and Respite Attestation DMS English 09/2024 PDF No
F-03240 Long-Term Care (LTC) Waiver Transportation Attestation DMS English 09/2024 Word No
F-03240 Long-Term Care (LTC) Waiver Transportation Attestation DMS English 09/2024 PDF No
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation DMS English 09/2024 Word No
F-03241 Long-Term Care (LTC) Waiver Vehicle Modification Attestation DMS English 09/2024 PDF No
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation DMS English 09/2024 Word No
F-03242 Long-Term Care (LTC) Waiver Vocational Futures Attestation DMS English 09/2024 PDF No
F-62595 Long-Term Care Facility Feeding Assistant Roster DQA English 06/2024 Word No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 Word No
F-01567 Long-Term Care Insurance Policy - Assignment of Benefits DMS English 12/2018 PDF No
F-01567S Long-Term Care Insurance Policy - Assignment of Benefits, Spanish DMS Spanish 12/2018 PDF No
F-03069 LTHD COVID-19 Antigen Test Distribution Program DPH English 04/2023 HTML No

Glossary

 
Last revised August 26, 2024