• PENALTY: A person who provides false information on this form may be subject to forfeiture and sanctions, as provided in Wis. Stat. § 50.065(6)(c) and Wis. Admin Code § DHS 12.05(4)
• Completion of this form to verify your eligibility for employment/service as a "caregiver" is required by Wis. Stat. § 50.065 and Wis. Admin Code ch. DHS 12. Failure to complete this form may result in denial or termination of your employment, contract or service agreement
Check the box that applies to you.
*
Specify Other*
Gender*
Select -
Male
Female
Answering "NO" to all questions does not guarantee employment, a contract, or service agreement.
Section A - Disclosures
Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts?
*
List each charge, when it occurred or the date of the charge, and the city and state where the court is located.
You may be asked to supply additional information, including a copy of the criminal complaint or any other relevant
court or police documents. *
Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts? *
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. *
Please note that Wis. Stat. § 48.981, Abused or neglected children and abused unborn children, may apply to information concerning
findings of child abuse and neglect.
Provide an explanation below, including when and where the incident(s) occurred. *
Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? *
Explain, including when and where it happened. *
Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client? *
Explain, including when and where it happened.*
Has any government or regulatory agency (other than the police) ever found that you abused an elderly person? *
Explain, including when and where it happened.*
Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?*
Explain, including credential name, limitations or restrictions, and time period.*
Section B - Other Required Information
Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services? *
Explain, including when and where it happened.*
Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility? *
Explain, including when and where it happened and the reason.*
Have you been discharged from a branch of the US Armed Forces, including any reserve component?*
Have you resided outside of Wisconsin in the last three (3) years? *
List each state and the dates you resided there.*
If you are employed by or applying for the State of Wisconsin, have you resided outside of Wisconsin in the last seven (7) years?*
List each state and the dates you resided there.*
Have you had a caregiver background check done within the last four (4) years? *
List the date of each check, and the name, address, and phone number of the person, facility, or government
agency that conducted each check.*
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?*
List the review date and the review result. You may be asked to provide a copy of the review decision.*
