Skills and Education
Please list two references we may contact (not members of your family).
Authorization and Release
I certify that the information given herein is complete and accurate to the best of my knowledge, and I authorize
investigation of the statements I have made. I release from any and all liability representatives of ProHealth
Care, Inc., for their acts performed in connection with evaluating my application, credentials, or references. I
understand that false or misleading information given in any application. or the withholding of information
deemed pertinent by ProHealth Care, Inc., can result in rejection of the application and will subject me to
I authorize my previous employer and any other reference sources to provide any and all information
concerning me, my prior employment, and my suitability for Volunteer service. I
release all parties from any
liability they may have for providing such information.
Background Information Disclosure (BID)
The Background Information Disclosure form (F-82064) 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.
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,
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
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.
A list of barred crimes and offenses requiring rehabilitation review is available from the regulatory agencies or through the Internet at
THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS / CARE PROVIDERS
(Referred to as “Entities”):
Programs Regulated under Chapter
48, Wis. Stats.
Treatment Foster Care,
Family Child Care Centers, Group Child Care Centers, Residential Care
Centers for Children and Youth, Child Placing
Agencies, Day Camps for Children, Family Foster
Homes for Children, Group Homes for Children, Shelter Care Facilities for
Children, and Certified
Family Child Care.
Programs Regulated under Chapters 50, 51, and 146, Wis. Stats.
Emergency Mental Health Service Programs, Mental Health Day Treatment Services
Community Mental Health,
Developmental Disabilities, AODA Services, Community Support Programs,
Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential
Complexes, Ambulance Service
Providers, Hospitals, Rural Medical Centers, Hospices, Nursing
Homes, Facilities for the Developmentally Disabled, and Home Health Agencies –
including those that
provide personal care
Providers contracted through Local School Boards
THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:
FAIR EMPLOYMENT ACT
- 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.
- Anyone who is a Child Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14).
- Anyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client (“nonclient resident”).
- Anyone who is licensed by DHS.
- Anyone who has a foster home licensed by DHS.
- Anyone certified by DHS.
- Anyone who is a Child Care Provider certified by a county department.
- Anyone registered by DHS.
- Anyone who is a board member or corporate officer who has access to the clients served.
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.
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.
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 (F-82064A) 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.
Acts, crimes, and offenses that may act as a bar or restriction
Other required information
A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.