Your entry contains words that are not allowed by this site.First Name: is required.
Your entry contains words that are not allowed by this site.Last Name: is required.
Your entry contains words that are not allowed by this site.Other names by which you have been known (including maiden name) is required.
Gender: is required. Your entry contains words that are not allowed by this site.Race: is required.
Your entry contains words that are not allowed by this site.Address: is required.
Your entry contains words that are not allowed by this site.City: is required.
Your entry contains words that are not allowed by this site.State: is required.
Your entry contains words that are not allowed by this site.Zip Code: is required.
Your entry contains words that are not allowed by this site.Phone: is required.
Your entry contains words that are not allowed by this site.Date of Birth: is required.
Your entry contains words that are not allowed by this site.Social Security Number: is required.
Your entry contains words that are not allowed by this site.Email: is required.Must be a valid email address.
Your entry contains words that are not allowed by this site.Availability Date: is required.
Volunteer Interest
Your entry contains words that are not allowed by this site.Volunteer areas of interest: is required.
I am available for volunteer assignments: is required.
Availability: Monday is required. Availability: Tuesday is required. Availability: Wednesday is required. Availability: Thursday is required. Availability: Friday is required. Availability: Saturday is required. Availability: Sunday is required. General Information
Your entry contains words that are not allowed by this site.In case of emergency whom should we notify is required.
Your entry contains words that are not allowed by this site.Relationship: is required.
Your entry contains words that are not allowed by this site.Address: is required.
Your entry contains words that are not allowed by this site.Phone: is required.
Have you ever been a volunteer or employed here before is required. Your entry contains words that are not allowed by this site.If yes, when is required.
Your entry contains words that are not allowed by this site.Job title: is required.
Are you acquainted with anyone who is a volunteer or employee here is required. Your entry contains words that are not allowed by this site.If yes, when is required.
Your entry contains words that are not allowed by this site.Position: is required.
Have you ever been convicted of any felony, misdemeanor or other offense, the circumstances of which substantially relate to the circumstances of the particular job or licensed activity you are applying for or are there any criminal charges pending against you is required. Your entry contains words that are not allowed by this site.If yes, described in full, including date(s): is required.
In the past three years, have you ever knowingly used any drugs (amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, opiates) other than those prescribed to you by a physician is required. Your entry contains words that are not allowed by this site.If yes, please furnish details: is required.
Skills and Education
Highest grade of education completed: is required.
Your entry contains words that are not allowed by this site.Diploma(s) or degree(s): is required.
Your entry contains words that are not allowed by this site.Other education or training completed: is required.
Your entry contains words that are not allowed by this site.Skills you have that may be useful in a Volunteer assignment: is required.
Experience
Your entry contains words that are not allowed by this site.Please furnish past employment and volunteer experience to assist us in assignment selection. (location, title and description): is required.
Employment
Your entry contains words that are not allowed by this site.Present or last employer: is required.
Your entry contains words that are not allowed by this site.Immediate Supervisor's Name: is required.
Your entry contains words that are not allowed by this site.Address: is required.
Your entry contains words that are not allowed by this site.Phone: is required.
Your entry contains words that are not allowed by this site.Dates Employed: From (Month/Year TO Month/Year): is required.
Your entry contains words that are not allowed by this site.Reason for Leaving: is required.
Your entry contains words that are not allowed by this site.Your title: is required.
Your entry contains words that are not allowed by this site.Description of Duties: is required.
References
Please list two references we may contact (not members of your family).
Your entry contains words that are not allowed by this site.Name: is required.
Your entry contains words that are not allowed by this site.Address: is required.
Your entry contains words that are not allowed by this site.Phone: is required.
Your entry contains words that are not allowed by this site.Relationship: is required.
Your entry contains words that are not allowed by this site.Name: is required.
Your entry contains words that are not allowed by this site.Address: is required.
Your entry contains words that are not allowed by this site.Phone: is required.
Your entry contains words that are not allowed by this site.Relationship: is required.
Authorization and Release
Are you able to perform the essential functions of the assignment for which you have applied, with or without reasonable accommodation is required. 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.
I agree to this Authorization and Release is required.
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.
Check the box that applies to you: is required. Your entry contains words that are not allowed by this site.Position Title (Complete only if you are a prospective employee or contractor, or a current employee or contractor.) is required.
Your entry contains words that are not allowed by this site.Business Name and Address - Employer or Care Provider (Entity): is required.
Acts, crimes, and offenses that may act as a bar or restriction
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 is required. Your entry contains words that are not allowed by this site.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 judgement of conviction, a copy of the criminal complaint, or any other relevant court or police documents. is required.
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.) is required. Your entry contains words that are not allowed by this site.If 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. is required.
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: is required. (Only employers and regulatory agencies entitled to obtain this information per sec. 48.981(7) are authorized to, and should, check this box.) is required.
Your entry contains words that are not allowed by this site.If Yes, explain, including when and where it happened. is required.
Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client is required. Your entry contains words that are not allowed by this site.If Yes, explain, including when and where it happened: is required.
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 is required. Your entry contains words that are not allowed by this site.If Yes, explain, including when and where it happened: is required.
Has any government or regulatory agency (other than the police) ever found that you abused an elderly person is required. Your entry contains words that are not allowed by this site.If Yes, explain, including when and where it happened. is required.
Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients is required. Your entry contains words that are not allowed by this site.If Yes, explain, including credential name, limitations or restrictions, and time period: is required.
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 is required. Your entry contains words that are not allowed by this site.If Yes, explain, including when and where it happened. is required.
Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility is required. Your entry contains words that are not allowed by this site.If Yes, explain, including when and where it happened and the reason. is required.
Have you been discharged from a branch of the US Armed Forces, including any reserve component is required. Your entry contains words that are not allowed by this site.If yes, indicate the year of discharge: is required.
Have you resided outside of Wisconsin in the last 3 years is required. Your entry contains words that are not allowed by this site.If Yes, list each state and the dates you lived there. is required.
Have you had a caregiver background check done within the last 4 years is required. Your entry contains words that are not allowed by this site.If 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. is required.
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 is required. Your entry contains words that are not allowed by this site.If Yes, list the review date and the review result. You may be asked to provide a copy of the review decision. is required.
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. is required.