Health Care Facility Fire Report, F-62500 (10/2018)

For adult family homes, community-based residential facilities, facilities serving people with development disabilities, hospitals, and nursing homes

All incidents of fire in an adult family home (AFH), a community-based residential facility (CBRF), a facility serving people with developmental disabilities (FDD), a hospital, or a nursing home must be reported to the Department of Health Services within 72 hours per Wis. Admin. Code §§ DHS 132.82(3)(e), DHS 134.82(3)(e), DHS 83.12(4)(e), DHS 124.36(11), DHS 88.05(4)(e) and Wis. Stat. § 50.035(4).
All fires are to be reported by completing and submitting this form.
Questions about completion of this form may be directed to dhsdqaplanreview@wi.gov or 608-264-7748.