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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-00004 Health and Employment Counseling Application DMS English 06/2020 Word No
F-00004 Health and Employment Counseling Application, Spanish DMS Spanish 06/2020 Word No
F-00004 Health and Employment Counseling Application, Hmong DMS Hmong 06/2020 Word No
F-00004A Health and Employment Counseling - I Think I Need More Time (PDF, 515 KB) DMS English 08/2018 PDF No
F-00004B Health and Employment Counseling - I Have Reached Employment DMS English 08/2018 PDF No
F-00005 Senior FMNP Agency Application to Participate DPH English 12/2008 Word No
F-00017 Blood Lead Lab Reporting DPH English 01/2020 Word No
F-00020 Drug Addition Review Request DMS English 04/2014 PDF No
F-00020 Drug Addition Review Request DMS English 04/2014 Word No
F-00021 HealthCheck Referral DMS English 01/2017 PDF No
F-00023 Case Management Agency Self-Audit Checklist DMS English 01/2017 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request: Completion Instructions DMS English 04/2017 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS English 04/2017 PDF No
F-00030 State and Specialty Maximum Allowed Cost Drug Pricing Review Request DMS English 04/2017 Word No
F-00036 Power of Attorney for Finance and Property DPH English 09/2010 HTML No
F-00039 Asbestos Course Accreditation - Initial DPH English 03/2009 PDF No
F-00040 Asbestos Course Accreditation - Renewal DPH English 03/2009 PDF No
F-00041 Asbestos Project Notification DPH English 12/2015 Word No
F-00043 Communication to Local Educational Agency Regarding Child Referral DMS English 02/2017 Word No
F-00044 User Agreement for System Access DES English 01/2017 Word No
F-00046 Family Care Program: Enrollment DPH English 03/2021 HTML No
F-00046 Family Care Program: Enrollment, Serbo-Croatian DPH Serbian (Serbo-Croatian) 03/2021 Word No
F-00046 Family Care Program: Enrollment, Arabic DPH Arabic 03/2021 Word No
F-00046 Family Care Program: Enrollment, Russian DPH Russian 03/2021 Word No
F-00046 Family Care Program: Enrollment, Spanish DPH Spanish 03/2021 Word No
F-00046 Family Care Program: Enrollment, Laotian DPH Laotian 03/2021 Word No
F-00046 Family Care Program: Enrollment, Chinese (Mandarin) DPH Chinese Mandarin 03/2021 Word No
F-00046 Family Care Program: Enrollment DPH English 03/2021 Word No
F-00046 Family Care Program: Enrollment, Hmong DPH Hmong 03/2021 Word No
F-00046 Family Care Program: Enrollment, Somali DPH Somali 03/2021 Word No
F-00046 Family Care Program: Enrollment, Large Print DPH English 03/2021 Word No
F-00047 Designated Asbestos Coordinator DPH English 09/2021 PDF No
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s), Spanish DPH Spanish 08/2016 PDF No
F-00048 Authorization To Receive Tetanus, diphtheria, acellular pertussis (Tdap), Meningococcal Conjugate (MCV4) and/or Human Papilloma Virus (HPV) Vaccine(s) DPH English 08/2016 PDF No
F-00049 Asbestos Principal Instructor Application DPH English 04/2022 PDF No
F-00052 Aging and Disability Resource Center (ADRC) Application: Instructions DPH English 03/2022 PDF No
F-00052 Aging and Disability Resource Center (ADRC) Application DPH English 03/2022 Word No
F-00052A Aging and Disability Resource Center (ADRC) Annual Budget DPH English 02/2017 Excel No
F-00052B Cares Data Access and Use Agreement / Designation of Cares Security and Data Exchange Coordinator DPH English 07/2016 Word No
F-00052C Organizational Transition for Dementia Care Specialist DPH English 11/2020 Word No
F-00052D ADRC Dissolution Planning Checklist DPH English 01/2023 Word No
F-00053 Notice of Intent to Submit an Application (ADRC) DPH English 03/2022 Word No
F-00054 ADRC/Aging/Tribal Agency Request for Approval of Alternative Staff Experience and/or Training DPH English 06/2022 Word No
F-00054A Request for Waiver of Requirements Relating to Co-Location of an ADRC and ICA/MCO or ADRC and Staff Subcontracted to an ICA/MCO DPH English 07/2016 Word No
F-00054B Request for Waiver of Requirements Relating to Organizational Separation when MCO Care Management is Subcontracted to the Same Agency Responsible for ADRC DPH English 07/2016 Word No
F-00054D Request for Waiver of the 0.5 Full-Time Equivalent Requirement for ADRC Staff DPH English 07/2016 Word No
F-00059 Outpatient Mental Health Clinic Application - DHS 35 (PDF, 135 KB) DQA English 08/2016 PDF No
F-00059 Outpatient Mental Health Clinic Application - DHS 35 DQA English 08/2016 Word No
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization DPH English 01/2021 Word No
F-00075 IRIS (Include, Respect, I Self-Direct) Authorization, Large Print DPH English 01/2021 Word No
Last revised January 23, 2023