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Wisconsin Department of Health Services

Division of Quality Assurance (608) 261-8319

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Background Check Forms


Caregiver Background Checks:

Background Information Disclosure and Instructions (BID)

Wisconsin Department of Justice (exit DHS) to access the following forms and instructions for completing them:

  • Wisconsin Criminal History Single Name Record Request Form DJ-LE-250

  • Wisconsin Criminal History Multiple Name Record Request Form DJ-LE-250A

  • Wisconsin Criminal History Account Application Form DJ-LE-251

Health Care Providers Only: DQA Regulated Entity Background Check Process

Rehabilitation Review:

  • Rehabilitation Review Request Instructions and Form, F-83263 (PDF 42 KB), for a caregiver required pursuant to Ch. DHS 12 (exit DHS; PDF 40 KB) to prove rehabilitation.

  • Counties, school boards, child placing agencies and tribes may order the forms to report rehabilitation review panel decisions to the Department of Health Services. See Ordering Printed Forms for the following:

    • Rehabilitation Review Panel Decision Report, F-83264

    • Instructions for Rehabilitation Review Panel Decision Report, F-83264A

    • Rehabilitation Review Appeals Report, F-83265

    • Instructions for Rehabilitation Review Appeals Report, F-83265A


Last Revised: August 01, 2014