A caregiver is a person who meets all of the following:
- is employed by or under contract with an entity;
- has regular, direct contact with the entity's clients or the personal property of the clients; and
- is under the entity's control.
This includes employees who provide direct care and may also include housekeeping, maintenance, dietary and administrative staff, if those persons are under the entity's control and have regular, direct contact with clients served by the entity.
As the license holder/legal representative, you must do the following:
- Have the employee or contractor complete a Background Information Disclosure (BID) form, F-82064 (PDF). Keep this completed BID on file.
- From the Wisconsin Department of Justice, Division of Law Enforcement Services - select Requesting a Record Check, obtain and complete a Wisconsin Criminal History Record Request (Single Subject Requests DJ-LE-250 or Multiple Subject Requests DJ-LE-250A), marking "Caregiver-General" under Request Purpose.
- Submit the DJ-LE-250 or DJ-LE-250A with appropriate fee, payable to "Department of Justice" and a self-addressed stamped envelope to:
Crime Information Bureau
Attn: Record Check Unit
P.O. Box 2688
Madison, WI 53701-2688
If you have an account with DOJ, you may request this information on the Criminal History Record Check website.
NOTE: Please do not submit forms for your employees to DQA. For more detailed information, see Chapter 2 of the Wisconsin Caregiver Program Manual, P-00038 (PDF)
A complete caregiver background check always consists of the following documents:
- A completed F-82064 Background Information Disclosure (BID) form and Appendix F-82069:
- English - Information Disclosure and Instructions, F-82064A (PDF)
English - Appendix, F-82069 (PDF)
- English - Information Disclosure and Instructions, F-82064A (Word)
English - Appendix, F-82069 (Word)
- Hmong - DAIM NTAWV QHIA MOJ KAB SIM TXOG KEEB KWM/LUS QHIA UA TXOG DAIM NTAWV QHIA TAWM TXOG KEEB KWM, F-82064H (PDF)
- Spanish - Divulgacion de Informacion de Antecedentes/Instrucciones, F-82064S (PDF)
- A response from the Department of Justice (DOJ) Wisconsin Criminal History Record Request, either a "no record found" response or a criminal record transcript (Wisconsin Identification Data). The following forms are available from the Wisconsin Department of Justice.
- 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
- A "Response to Caregiver Background Check" letter from the Department of Health Services (DHS) that reports the person's administrative finding or licensing restriction status.
These three items are to be retained with the employee's records and to be made available when requested by DQA staff for survey purposes.
Other documentation must be obtained by the entity when information is needed to complete the background check, such as other state's conviction records, military discharge papers, arrest and conviction disposition information from local clerks of courts or tribal courts, etc.