DHS Background Check – Allen Cares Adult Family Home

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WI DEPT OF HEALTH SERVICES BACKGROUND CHECK

Name *

First

Middle

Last

Please state your full middle name.

Please state what applies to you. *

Name of the Business you're applying to: *

SECTION A – DISCLOSURES

1. Do you have any criminal charges pending against you, including in federal, state, local, military and tribal courts? If Yes, 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. *

Yes
No

Explanation

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2. Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts? 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. *

Yes
No

Explanation

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3. Please note that Wis. Stat. 48.981, Abused or neglected children and abused unborn children, may apply to informal findings of child abuse and neglect. Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? Provide an explanation below, including when and where the incident(s) occurred. *

Yes
No

Explanation

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4. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? If Yes, explain, including when and where it happened. *

Yes
No

Explanation

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5. 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? If Yes, explain, including when and where it happened. *

Yes
No

Explanation

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6. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person? If Yes, explain, including when and where it happened. *

Yes
No

Explanation

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7. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to client? If Yes, explain, including credentials name, limitations or restrictions, and time period. *

Yes
No

Explanation

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SECTION B – OTHER REQUIRED INFORMATIONS

1. Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services? If Yes, explain, including when and where it happened. *

Yes
No

Explanation

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2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility? If yes, explain, including when and where it happened and the reason. *

Yes
No

Explanation

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3. Have you been discharged from a branch of the US Armed Forces, including any reserve component? If Yes, indicate the year of discharge: Attach a copy of your DD214, if you were discharged within the last (3) years. *

Yes
No

Explanation

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4. Have you resided outside of Wisconsin in the last three (3) years? If Yes, list the dates you have resided there. *

Yes
No

Explanation

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5. If you are employed by or applying for the State of Wisconsin, have you resided outside Wisconsin in the last seven (7) years? If Yes, list each state and the dates you resided there. *

Yes
No

Explanation

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Read and initial the following statement. I have completed and reviewed this form (F-82064, BID) and affirm that the information is true and correct as

Name *

First

Middle

Last

Social Security Number

Initial *

Clear Signature

Date / Time *

Date

Time