Thank you for expressing an interest in Oconomowoc Memorial Hospital's Volunteer Service Program. It is the policy of this Hospital to extend its volunteer opportunities to qualified persons on a nondiscriminatory basis. Selection shall be made without regard to age, race, color, sex, national origin, disability of any other class protected by law.


Volunteer Interest















General Information





Skills and Education

Experience

Employment

References

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 immediate termination.

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, 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.

A list of barred crimes and offenses requiring 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”):

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 for Children,
Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs,
Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment
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 services.

Others

Child Care Providers contracted through Local School Boards

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:

  • 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.
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 IDENTIFIABLEINFORMATION
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.