F 82064 Form – Fill Out and Use This PDF

BACKGROUND INFORMATION DISCLOSURE (BID)

INSTRUCTIONS

The Background Information Disclosure form (F­82064) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment, contract, residency, and regulatory decisions. Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency. NOTE: If you are an owner, operator, board member, or non­client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F­82064, and the Appendix, F­82069, and submit both forms to the address noted in the Appendix Instructions.

CAREGIVER BACKGROUND CHECK LAW

In accordance with the provisions of Chapters 48.685 and 50.065, Wis. Stats., for persons who have been convicted of certain acts, crimes, or offenses:

1.The Department of Health Services (DHS) may not license, certify, or register the person or entity (Note: Employers and Care Providers are referred to as “entities”);

2.A county agency may not certify a child care or license a foster or treatment foster home;

3.A child placing agency may not license a foster or treatment foster home or contract with an adoptive parent applicant for a child adoption;

4.A school board may not contract with a licensed child care provider; and

5.An entity may not employ, contract with or, permit persons to reside at the entity.

The list of offenses affecting caregiver eligibility that require rehabilitation review is available from the regulatory agencies or through the Internet at http://DHS.wisconsin.gov/caregiver/StatutesINDEX.HTM.

THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS / CARE PROVIDERS (Referred to as “Entities”):

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:

ｸAnyone employed by or contracting with a covered entity who has access to the clients served, except if the access is infrequent or sporadic and service is not directly related to care of the client. Exception: Emergency medical technicians and first responders are not covered under the Caregiver Law.

ｸAnyone who is a Child Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14).

ｸAnyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client (“non­client resident”).

ｸAnyone who is licensed by DHS.

ｸAnyone who has a foster home licensed by DHS.

ｸAnyone certified by DHS.

ｸAnyone who is a Child Care Provider certified by a county department.

ｸAnyone registered by DHS.

ｸAnyone who is a board member or corporate officer who has access to the clients served.

FAIR EMPLOYMENT ACT

Wisconsin’s Fair Employment Law, Chapters 111.31 – 111.395, Wis. Stats., prohibits discrimination because of a criminal record or pending charge; however, it is not discrimination to decline to hire or license a person based on the person’s arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity.

PERSONALLY IDENTIFIABLE INFORMATION

This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. For example, the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. The Department of Health Services’ Caregiver Misconduct Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misappropriation of a client’s property.

BACKGROUND INFORMATION DISCLOSURE (BID)

Completion of this form is required under the provisions of Chapters 48.685 and 50.065, Wis. Stats. Failure to comply may result in a denial or revocation of your license, certification, or registration; or denial or termination of your employment or contract. Refer to the instructions (F­82064A) on page 1 for additional information. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches.

PLEASE PRINT OR TYPE YOUR ANSWERS.

NOTE: If you are an owner, operator, board member, or non­client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F­82064, and the Appendix, F­82069, and submit both forms to the address noted in the Appendix Instructions.

Business Name and Address – Employer or Care Provider (Entity)

1.Do you have any criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts?

ﾾ If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is

located. You may be asked to supply additional information including a certified copy of the judgment of conviction, a copy of the criminal complaint, or any other relevant court or police documents.

2.Were you ever found to be (adjudicated) delinquent by a court of law on or after your 10th birthday for a crime or offense? (NOTE: A response to this question is only required for group and family day care centers for children and day camps for children.)

ﾾIf Yes, list each crime, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents.

3.Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? A response is required if the box below is checked:

ﾉ(Only employers and regulatory agencies entitled to obtain this information per sec. 48.981(7) are authorized to, and should, check this box.)

ﾾ If Yes, explain, including when and where it happened.

5.Have you had a caregiver background check done within the last 4 years?

ﾾIf Yes, list the date of each check, and the name, address, and phone number of the person, facility, or government agency that conducted each check.

6.Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS designated tribe?

ﾾIf Yes, list the review date and the review result. You may be asked to provide a copy of the review decision.

A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.

I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in DHS 12.05 (4), Wis. Adm. Code.