Background Information Disclosure (BID) – Department of Health Services form F-82064

Step 1 of 4

• Completion of this form is required under the provisions of Wis. Stat. § 50.065. Failure to comply may result in a denial or revocation of your license, certification, or registration, or denial or termination of your employment contract. • Refer to DQA form F-82064A, BID Instructions, 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(Required)

Employee / Contractor (including new applicant)

Household member (lives on premises, but is not a client)

Applicant for a license, certification, or registration (including continuation or renewal)

Other - Specify:

Other(Required)

Full Legal Name(Required)

First Middle Last

Position Title (Complete only if a prospective or current employee or contractor.)(Required)

Birth Date(Required)

Sex(Required)

Any Other Names By Which You Have Been Known (Including Maiden Name). Enter "none" if not known by any other names. *(Required)

Race / Ethnicity (Check ONLY One.)(Required)

American Indian or Alaskan Native

Asian or Pacific Islander

Black

White

Other

Social Security Number(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Business Name and Address - Employer or Care Provider (Entity)(Required)

1. Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts?(Required)

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.(Required)

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

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 or conviction, a copy of the criminal complaint, or any other relevant court or police documents.(Required)

Wis. Stat. § 48.981 Abused and neglected children and abused unborn children. (7)(a) CONFIDENTIALITY. "All reports made under this section, notices provided under sub. (3)(bm), and records may be disclosed only to the persons identified in this section. ☑ If you are the employer or prospective employer of the person completing this form and are entitled to obtain this information per the above, check this box.

3. Has the government or regulatory agency (other than the police) ever found that you committed child abuse or neglect?(Required)

4. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client?(Required)

If Yes, explain, including when and where it happened.(Required)

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?(Required)

If Yes, explain, including when and where it happened.(Required)

6. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person?(Required)

If Yes, explain, including when and where it happened.(Required)

7. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?(Required)

If Yes, explain, including credential name, limitations or restrictions, and time period.(Required)