Background Check Forms

ALL PROGRAMS

Caregiver Background Checks:

Background Information Disclosure and Instructions (BID)

• English - Information Disclosure and Instructions - PDF Version: F-82064A (PDF, 46 KB)
   

• English - Information Disclosure and Instructions - Word Fillable Version: F-82064A (Word, 97 KB)
   

• Hmong - DAIM NTAWV QHIA MOJ KAB SIM TXOG KEEB KWM/LUS QHIA UA TXOG DAIM NTAWV QHIA TAWM TXOG KEEB KWM: F-82064H (PDF, 50 KB)
   

• Spanish - Divulgacion de Informacion de Antecedentes/Instrucciones: F-82064S (PDF, 49 KB)

Click on 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:

• Click on Rehabilitation Review Request Instructions and Form (PDF 42 KB), F-83263, if you are 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 Rehab Review Panel Decision Report, F-83264A

  • Rehabilitation Review Appeals Report, F-83265

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

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Last Revised: April 29, 2013