Background Information Disclosure (BID)

APPLICANT INFORMATION

Name (First & Middle) *

Last Name *

Email Address Position Title (if employee or contractor) Any Other Names Used (Including Maiden Name)

Birth Date *

Gender

Race

Social Security Number(s) * Home Address *

City *

State

Zip Code *

Business Name and Address – Employer or Care Provider

Check the box that applies to you: *

Employee / Contractor (including new applicant) Applicant for a license, certification, or registration Household member / lives on premises – not a client Other (Specify)

If "Other", specify:

SECTION A – ACTS, CRIMES, AND OFFENSES

Do you have any criminal charges pending or were you ever convicted of any crime?

Yes No

Were you ever adjudicated delinquent on or after your 10th birthday?

Yes No

Has any agency found that you committed child abuse or neglect?

Yes No

Has any agency found that you abused or neglected any person or client?

Yes No

Has any agency found that you misappropriated property?

Yes No

Has any agency found that you abused an elderly person?

Yes No

Do you have a government-issued credential that is not current or is limited?

Yes No

SECTION B – OTHER REQUIRED INFORMATION

Has any agency ever limited, denied, or revoked your license or certification?

Yes No

Has any agency denied or restricted your ability to live on care facility premises?

Yes No

Have you been discharged from the U.S. Armed Forces?

Yes No

Have you resided outside Wisconsin in the last 3 years?

Yes No

Have you had a caregiver background check in the last 4 years?

Yes No

Have you requested a rehabilitation review?

Yes No

ATTACH SUPPORTING DOCUMENTS

Upload supporting documents (if applicable):

You can attach multiple files. Maximum file size: 10MB each. Accepted formats: PDF, DOC, DOCX, TXT, JPG, PNG, ZIP, RAR