2021 Manitou Background Information Disclosure

Background Information Disclosure
Completion of this form is required under the provisions of Wis. Stat. § 48.685 and Wis. Admin. Code § DCF 12.03. Pursuant to Wis. Stat. § 48.685, this form must be completed prior to licensure, certification, employment or non-client residency and is only valid for 120 days. Failure to comply may result in a denial or revocation of your license or certification; denial or termination of your employment or contract; or denial or revocation of the license or certification for a child care center location at which you reside. Providing your social security number (SSN) is voluntary; not providing it could result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, Wis. Stat. §15.04(1)(m)].
Check the box that applies to you. *

Current or Prospective Employee / Contractor Applicant for a license or certification (including continuation or renewal) Household member / lives on premises – but not a client (anyone 12 years of age or over.)
Name *

First Name Middle Name Last Name
Position/Title (if applicable)
Any Other Names By Which You Have Been Known (Including Maiden Name)

First Name Last Name
Birthdate *

Month Day Year
Date
Gender
Race

American Indian or Alaskan Native Asian or Pacific Islander Black White Unknown
Social Security Number
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name and address of Potential Employer, Licensing Agency, Certifying Agency, or the child care center at which you reside or will reside.

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SECTION A – ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION
1. Do you have any criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, county, local, military, and tribal courts? Have you ever been convicted of another offense such as a municipal ordinance violation or a civil offense under a local ordinance? *

Yes No
If Yes, list each pending charge or conviction, when it occurred, the date or arrest and conviction if applicable, and the city and state where the court is located. You may be asked to supply additional information including certified copy of the judgment of conviction, a copy of the criminal complaint or any other relevant court or police documents.
2. Were you ever adjudicated delinquent by a court of law, including tribal court, on or after your 12th birthday and before your 18th birthday, for a crime or other offense such as a municipal ordinance violation or a civil offense under a local ordinance? *

Yes No
If Yes, list each crime or offense, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents.
3. Are you currently under community supervision by a state, federal or tribal agency (i.e. probation, extended supervision or parole)? *

Yes No
If Yes, provide the name, address and phone number of the agency.
4. Are you currently, or have you ever been, required to be registered on a state, tribal or national sex offender registry? *

Yes No
If Yes, explain, including the location, reason for registration and length of time required to be registered.
5. Are you currently the subject of a child abuse or neglect investigation by a government or regulatory agency? *

Yes No
If Yes, explain and provide the name of the agency conducting the investigation.
6. Has any government or regulatory agency (other than the police) ever found that you abused or neglected a child? *

Yes No
If Yes, explain, including when and where it happened and the name of the agency that made the finding.
7. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? *

Yes No
If Yes, explain, including when and where it happened.
8. 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? *

Yes No
If Yes, explain, including when and where it happened.
9. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person? *

Yes No
If Yes, explain, including when and where it happened.
10. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients? *

Yes No
If Yes, explain, including credential name, limitations or restrictions, and time period.
SECTION B – OTHER REQUIRED INFORMATION
1. Has any government or regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services? *

Yes No
If Yes, explain, including when and where it happened.
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? *

Yes No
If Yes, explain, including when and where it happened and the reason.
3. Have you been discharged from a branch of the U.S. Armed Forces, including any reserve component? *

Yes No
If yes, indicate the year of discharge. Provide a copy of your DD214 if you were discharged within the last 3 years.
4. Have you resided outside of Wisconsin in the last 5 years? *

Yes No
If Yes, list each state and the dates you lived there.
5. Have you had a caregiver background check done within the last 4 years? *

Yes No
If 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.
6. Have you ever requested a rehabilitation review with the Wisconsin Department of Health Services or the Department Children and Families, a county department, a private child placing agency, school board or tribe? *

Yes No
If Yes, list the review date, the result, the agency that conducted the review and attach a copy of the review decision.
A “NO” answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.
I understand, under penalty of law that the information provided above is truthful and accurate to the best of my knowledge. I understand that knowingly providing false information or omitting information may result in a forfeiture and other sanctions as provided by law. *

Clear
Date of Signature *
Should be Empty: