Department of Health Services
F-82064 (02/2026)
State of Wisconsin
Wis. Stat. § 50.065/Wis. Admin Code § DHS 12.05(4)
Page 1 of 3
Background Information Disclosure (BID)For Entity Employees and Contractors
Purpose: State and federal law require background checks for certain types of employment, contract, or other roles involving contact with vulnerable persons receiving care or treatment. The information you provide on this form will be used to verify your eligibility for such a role. Providing inaccurate or incomplete information on this form may result in a forfeiture or other sanction, as provided in Wis. Stats. § 50.065(6)(c).
Type
Type
Applicant/employee
Volunteer
Contractor
Household member
Student
Other
Describe the position for which you are applying or renewing:
Applicant information
Name (First, Middle, Last):
First Name
Middle Initial
Last Name
Social Security number:
Date of birth (MM/DD/YYYY):
-
Month
-
Day
Year
Date
Sex:
Male
Female
Phone number:
Format: (000) 000-0000.
Address - Street:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you had or used any other names, including prior to marriage?
Yes
No
If yes, list each name fully:
Employer or organization verifying eligibility
Name of employer or organization that asked you to complete this form:
Address - Street:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Disclosures
1. Pending criminal charges
Do you have any criminal charges pending against you, including in federal, state, local, military, and tribal courts?
Yes
No
If yes, describe the charge and indicate the name of the court, the state, city, month and year you were charged.
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F-82064
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2. Convictions for crimes
Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts, or in another country?
Yes
No
If yes, describe the crime and indicate the name of the court, the state, city, month and year you were convicted.
3. Abuse or neglected or a child
Please note that Wis. Stat. § 48.981, abused or neglected children and abused unborn children, may apply to information concerning findings of child abuse and neglect.
Has a government or regulatory agency (other than the police) ever found that you abuse or neglected a child?
Yes
No
If yes, describe the conduct and indicate the agency that made the finding, the state, city, month and year of the finding.
4. Abuse or neglect of an adult
Has a government or regulatory agency (other than the police) ever found that you abused or neglected an adult?
Yes
No
If yes, describe the conduct and indicate the agency that made the finding, the state, city, month and year of the finding.
5. Stealing or other misappropriation
Has a government or regulatory agency (other than the police) ever found that you stole or misappropriated (improperly took or used) a person's property (e.g., money, medications, etc.), identity, or financial information (e.g., credit card, checks, etc.)?
Yes
No
If yes, describe the conduct and indicate the agency that made the finding, the state, city, month and year it occurred.
6. Restriction on credential
Do you have a government issued credential that is not current or has been revoked, suspended, or that limits you in any way from providing care to clients?
Yes
No
If yes, identify the type of credential and indicate the credentialing agency, the restriction, and the state, city, month and year it was issued.
7. Denial, revocation, or limitation on license, certification, or registration
Has a government or regulatory agency ever denied, revoked, or limited your license, certification, or registration to provide care, treatment, or educational services?
Yes
No
If yes, indicate the license, certification, or registration type and indicate the issuing agency. Include a description of the denial, revocation, or limitation, and the state, city, month and year it was issued.
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F-82064
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8. Denial, revocation, or limitation on ability to reside on certain premises
Has a government or regulatory agency ever denied, revoked or limited your ability to live on the premises of a facility that provides care or treatment?
Yes
No
If yes, describe the denial, revocation, or limitation and identify the issuing agency, the state, city, month and year issued.
9. Rehabilitation review
Have you ever requested a rehabilitation review from the Wisconsin Department of Health Services, a county department, private child placing agency, school board, or DHS- designated tribe?
Yes
No
If yes, indicate the agency that conducted the review, the outcome, month, and year of the review.
Note: You must provide a copy of your rehabilitation review letter to your employer or organization. Your employer or organization must verify your status with the agency that issued the decision.
10. Armed forces
Have you been discharged from a branch of the US Armed Forces, including any reserve component?
Yes
No
If yes, indicate the month and year of discharge.
Note: You must provide your DD214 to your employer/agency, if you were discharged within the last three (3) years.
11. Out-of-state residence
Have you resided outside of Wisconsin in the last three (3) years?
Yes
No
If yes, list each state and the dates you resided there.
12. Government employee
Are you applying or renewing eligibility to work as a government employee for the State of Wisconsin (e.g. a state agency, treatment facility, institute, etc.)?
Yes
No
If no, skip to the attestation below. If yes, have you resided outside of Wisconsin in the last seven (7) years?
Yes
No
If yes, list each state and the dates you resided there.
Review your responses and the following attestation carefully before signing.
Attestation
I have completed and reviewed this form. The information I provided is accurate and complete. I understand that providing inaccurate or incomplete information on this form may result in a forfeiture or other sanction, as provided in Wis. Stats. § 50.065(6)(c).
Signature — Person completing this form:
Date
-
Month
-
Day
Year
Date
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