Afghanistan Refugee Assistance Name *Email *I would like to assist *As a volunteerAs an organization collection contactAs a parish collection contactName of Organization or Parish I have my COVID-19 Vaccine *YesNoBACKGROUND INFORMATION DISCLOSURE (BID) • PENALTY: Knowingly providing false information or omitting information may result in a forfeiture of up to $1,000 and other sanctions as provided in Wis. Admin. Code § DHS 12.05(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 or contract. • Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches. • Refer to DQA form F-82064A, BID Instructions, for additional information.Check the box that applies to you. *NOTE: If you are an owner, operator, board member, or non-client resident of a facility regulated by the Division of Quality Assurance (DQA), complete the BID, F-82064 and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.Other-VolunteerFull Legal Name – First *Middle *Last *Birthdate Phone Number *Sex *MaleFemaleAny Other Names By Which You Have Been Known (Including Maiden Name) Race / Ethnicity (Check ONLY one.) American Indian or Alaskan Native American Indian or Alaskan NativeAsian or Pacific IslanderBlackWhiteUnknownAddress Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountryAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweBusiness Name and Address – Employer or Care Provider (Entity) A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.SECTION A – ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION Question 1 *Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts? 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.YesNoQuestion 2 *Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts? 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 judgment of conviction, a copy of the criminal complaint, or any other relevant court or police documents.YesNoIMPORTANT: Read before completing item 3. 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 maintained by an agency and other persons, officials, and institutions shall be confidential.” Reports 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.Question 3 *Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect?YesNoIf the above box has been checked, provide an explanation below, including when and where the incident(s) occurred. Question 4 *Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client?YesNoIf Yes, explain, including when and where it happened. Question 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?YesNoIf Yes, explain, including when and where it happened. Question 6 *Has any government or regulatory agency (other than the police) ever found that you abused an elderly person?YesNoIf Yes, explain, including when and where it happened. Question 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?YesNoIf Yes, explain, including credential name, limitations or restrictions, and time period. SECTION B – OTHER REQUIRED INFORMATIONQuestion 1 *Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services?YesNoIf Yes, explain, including when and where it happened. Question 2 *Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility?YesNoIf Yes, explain, including when and where it happened and the reason. Question 3 *Have you been discharged from a branch of the US Armed Forces, including any reserve component?YesNoIf Yes, indicate the year of discharge: Attach a copy of your DD214, if you were discharged within the last three (3) years. Question 4 *Have you resided outside of Wisconsin in the last three (3) years?YesNoYes, list each state and the dates you resided there. Question 5 *If you are employed by or applying for the State of Wisconsin, have you resided outside of Wisconsin in the last seven (7) years?YesNoIf Yes, list each state and the dates you resided there. Question 6 *Have you had a caregiver background check done within the last four (4) years?YesNoIf Yes, list the date of each check, and the name, address, and phone number of the person, facility, or government agency that conducted each check. Question 7 *Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS-designated tribe?YesNoIf Yes, list the review date and the review result. You may be asked to provide a copy of the review decision. Read and initial the following statement: I have completed and reviewed this form (F-82064, BID) and affirm that the information is true and correct as of today’s date. *Date * VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
