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STATE OF WISCONSIN DEPARTMENT OF HEALTH SERVICES F-82064H (01/09)

DAIM NTAWV QHIA TAWM KEEB KWM YAV DHAU LOS COV LUS QHIA

BACKGROUND INFORMATION DISCLOSURE (BID) INSTRUCTIONS

Daim Ntawv Qhia Tawm Keeb Kwm Yav Dhau Los (F-82064) yog ua raws li Wisconsin Tsab Cai Tshawb Nrhiav Tus Neeg Tu Lwm Tus Keeb Kwm Yav Dhau Los (Wisconsin Caregiver Background Check Law) los pab cov tswv hauj lwm thiab tsoom fwv cov chaw ua hauj lwm tswj txoj cai txiav txim txog kev ua hauj lwm, kev ua ntawv cog lus, kev nyob, thiab kev tswj cai. Sau kom tiav thiab xa tag nrho daim ntawv thiab muab cov lus qhia los ntawm tus tswv hauj lwm los yog qhov chaw ua hauj lwm tswj txoj cai rov qab. TSAB CAI TSHAWB NRHIAV TUS NEEG TU LWM TUS KEEB KWM YAV DHAU LOS (CAREGIVER BACKGROUND CHECK LAW) Raws li cov cai hauv Chapters 48.685 thiab 50.065, Wis. Stats., rau cov neeg uas tau raug txim los ntawm tej qhov ua txhaum cai: 1. The Department of Health Services (DHS) yuav tsis muab ntawv pov thawj, ntawv lees paub, los yog muab npe nkag rau tus neeg los yog qhov chaw (Lus cim: Cov tswv hauj lwm thiab cov muab kev pab yog muab hu tias "cov chaw"); 2. Ib lub county qhov chaw ua hauj lwm yuav tsis muab ntawv lees paub rau ib qhov chaw zov me nyuam los yog muab ntawv pov thawj rau ib lub tsev tu me nyuam los sis ib lub tsev pab kho me nyuam; 3. Ib qhov chaw ua hauj lwm pab me nyuam yuav tsis muab ntawv pov thawj rau ib lub tsev tu me nyuam los sis ib lub tsev kho me nyuam los sis ua ntawv cog lus nrog ib tug niam txiv uas yuav me nyuam los tu ua nws me nyuam; 4. Ib pawg tswj hwm tsev kawm ntawv yuav tsis ua ntawv cog lus nrog ib lub tsev uas muaj ntawv pov thawj zov me nyuam; thiab 5. Ib qhov chaw yuav tsis ntiav, ua ntawv cog lus nrog, los yog cia cov neeg los nyob rau ntawm qhov chaw. Ib daim ntawv teev cov kev ua txhaum uas muaj kev cuam tshuam rau kev muab ntawv tso cai rau cov neeg tu lwm tus uas yuav tsum tau rov qab muab xyuas dua muaj nyob rau ntawm cov chaw ua hauj lwm tswj txoj cai los yog nyob rau ntawm qhov Internet http://dhs.wisconsin.gov/caregiver/StatutesINDEX.HTM. TSAB CAI HAIS TXOG TUS NEEG TU LWM TUS YOG SIV RAU COV TSWV HAUJ LWM / COV MUAB KEV PAB (HU UA

"COV CHAW") NRAM QAB NO:

Cov Kev Pab Cuam Uas Nyob Raws Li Cov Cai Hauv Chapter 48, Wis. Stats.

Treatment Foster Care, Family Child Care Centers, Group Child Care Centers, Residential Care Centers for Children and Youth, Child Placing Agencies, Day Camps for Children, Family Foster Homes for Children, Group Homes for Children, Shelter Care Facilities for Children, and Certified Family Child Care.

Cov Kev Pab Cuam Uas Nyob Raws Li Cov Cai Hauv Chapter 50, 51, thiab 146, Wis. Stats.

Emergency Mental Health Service Programs, Mental Health Day Treatment Services for Children, Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs, Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment Complexes, Ambulance Service Providers, Hospitals, Rural Medical Centers, Hospices, Nursing Homes, Facilities for the Developmentally Disabled, and Home Health Agencies ­ nrog rau cov uas muab kev pab tu tus kheej (personal care services).

Lwm Cov

Cov Chaw Zov Me Nyuam (Child Care Providers) uas muaj ntawv cov lus los ntawm Cov Pawg Tswj Hwm Tsev Kawm Ntawv Hauv Zos (Local School Boards)

F-82064AH (01/09)

TSAB CAI HAIS TXOG TUS NEEG TU LWM TUS YOG SIV RAU COV NEEG NRAM NO: · Tus neeg twg uas ua hauj lwm los sis tau ntawv cog lus nrog rau ib qhov chaw uas cuag tau cov neeg tau txais kev pab, tshwj hais tias ntshe qhov kev cuag tau ntawd tsis yog tas mus li los sis tej zaum thiaj li muaj xwb thiab qhov kev pab tsis yog ntsig txog qhov kev pab tu tus neeg tau txais kev pab. · Tus neeg twg uas yog Tus Muab Kev Pab Zov Me Nyuam uas muaj ntawv cog lus nrog rau ib Pawg Tswj Hwm Tsev Kawm Ntawv raws li Wisconsin Txoj Cai 120.13 (14). · Tus neeg twg uas nyob rau ntawm qhov chaw thiab muaj 10 xyoo los sis tshaj saud, tiam sis tsis yog ib tug neeg tau txais kev pab ("nonclient resident") nyob rau ntawd. · Tus neeg twg uas tau ntawv pov thawj los ntawm DHS. · Tus neeg twg uas muaj ib lub tsev tu me nyuam uas tau ntawv pov thawj los ntawm DHS. · Tus neeg twg uas tau ntawv lees paub los ntawm DHS. · Tus neeg twg uas yog ib Tus Muab Kev Pab Zov Me Nyuam uas tau ntawv lees paub los ntawm ib lub county qhov chaw ua hauj lwm. · Tus neeg twg uas muab npe tso rau los ntawm DHS. · Tus neeg twg uas yog ib tug tswj hwm los yog tus khiav hauj lwm uas cuag tau cov neeg tau txais kev pab. TSAB CAI HAIS TXOG KEV NCAJ NCEES RAU KEV HAUJ LWM (FAIR EMPLOYMENT ACT) Wisconsin Tsab Cai Hais Txog Kev Ncaj Ncees Rau Kev Ua Hauj Lwm, Chapters 111.31 - 111.395, Wis. Stats., txwv tsis pub muaj kev ntxub ntxaug los ntawm kev tau ua txhaum cai yav tas los los yog tseem muaj txim hais tsis tau tiav; tiam sis, nws yuav tsis yog kev ntxub ntxaug txog qhov uas tsis kam txais ib tus neeg ua hauj lwm los sis muab ntaub ntawv pov thawj rau nws los ntawm qhov nws tau raug ntes los yog raug txhom yav tas los ntawd uas muaj feem xyuam ze heev rau txoj hauj lwm los yog qhov muab ntawv pov thawj ntawd. COV NTAUB NTAWV QHIA TXOG TUS KHEEJ TIAS YOG LEEJ TWG (PERSONALLY IDENTIFIABLE INFORMATION) Cov ntaub ntawv no yog siv los muab ntau yam hais txog tus kheej kom tau raws li cov tshooj cai uas nyob rau hauv Wisconsin Tsab Cai Tshawb Nrhiav Tus Neeg Tu Lwm Tus Keeb Kwm Yav Dhau Los. Qhov muab koj tus social security number yog ib qho cim qhia tseeb txog tus kheej uas pab tiv thaiv kom tsis muaj qhov yuam kev. Piv txwv li, Department of Justice yuav siv cov social security numbers, npe, poj niam/txiv neej, haiv neeg, thiab hnub yug los xyuas kom tsis txhob muaj qhov yuam kev ntawm cov neeg uas tau raug txim. Department of Health Services' Caregiver Misconduct Registry yuav siv cov social security numbers los pab qhia kom paub tias yog leej twg los tiv thaiv qhov yuam kev ntawm cov neeg uas tsim txom los yog tsis saib tsis xyuas ib tug neeg uas tau txais kev pab los sis kev muab tso tsis yog rau tus neeg uas tau txais kev pab tej khoom siv ntiag tug.

DEPARTMENT OF HEALTH SERVICES F-82064H (01/09)

STATE OF WISCONSIN

DAIM NTAWV QHIA TAWM KEEB KWM YAV DHAU LOS

BACKGROUND INFORMATION DISCLOSURE (BID)

Qhov ua daim ntawv no yog ua raws li cov tshooj cai ntawm Chapters 48.685 thiab 50.065, Wis. Stats. Yog tsis ua raws li hais yuav tsis kam muab koj daim ntawv tso cai, daim ntawv lees paub, los yog daim ntawv sau npe rau koj los yog yuav raug muab cov ntawv no xa rov qab; los yog yuav tsis kam muab hauj lwm los yog ntawv cov lus rau koj los yog muab txiav kom tu. Mus xyuas ntawv phab teev Cov Lus Qhia (F-82064 AH) kom paub ntxiv. Qhov muab koj tus social security number yog nyob ntawm siab; tiam sis, koj tus social security number yog ib tus cim tshwj xeeb qhia tau zoo kom paub meej tias yog leej twg uas siv los tiv thaiv qhov yuam kev rau lwm tus.

THOV SAU KOJ COV LUS TEB NRAM QAB NO KOM POM TSEEB.

Kos rau lub box uas hais raug rau koj. Tus neeg ua hauj lwm / Tus Tau Ntawv Cog Lus (xam tus ua ntawv thov tshiab tib sis) Tus ua ntawv thov ib daim ntawv pov thawj los yog ntawv lees paub los yog ntawv sau npe (xam cov uas muaj mus ntxiv los sis ua dua tshiab)

Cov neeg hauv tsev neeg / nyob rau ntawm qhov chaw ­ tiam sis tsis yog ib tug neeg tau kev pab Lwm yam ­ thov qhia kom meej:

LUS CIM: Yog tias koj yog ib tus tswv, tus khiav hauj lwm, tus tswj hwm, los yog ib tug neeg uas tsis yog tus tau kev pab ntawm ib qhov chaw uas yog Division of Quality Assurance (DQA) yog tus muab cov cai tswj, koj yuav tau ua Daim Ntawv Qhia Tawm Keeb Kwm Yav Dhau Los, F-82064, thiab Daim Appendix, F-82069, thiab muab ob daim xa tib si mus rau qhov chaw uas teev nyob rau ntawm Daim Appendix Cov Lus Qhia.

Npe ­ Lub Npe thiab Npe Nruab Nrab Npe ­ Lub Xeem Txoj Hauj Lwm Nws Tuav (Teev rau yog tias koj yog tus neeg ua hauj lwm los yog tus tau txais ntawv cog lus, los yog tus ua hauj lwm tam sim no los yog tus tau txais ntawv cog lus.) Hnub Yug Poj Niam/Txiv Neej (M / F) Haiv Neeg

Lwm Cov Npe Uas Luag Paub Koj Yav Dhau Los (nrog rau Npe Hluas Nkauj)

Chaw Nyob Txoj Kev, Zos, Xeev, Zip Code

Social Security Number

Qhov Lag Luam Lub Npe thiab Chaw Nyob - Tus Tswv Hauj Lwm los sis Tus Muab Kev Pab (Qhov Chaw )

TSHOOJ A ­ COV KEV UA TXHAUM CAI UAS YUAV LOS THAIV LOS YOG TXWV

MUAJ

TSIS MUAJ

1. Koj puas muaj ib cov txim ua txhaum cai twg uas tseem hais tsis tau tas los yog muaj txim yav dhau los tsis hais nyob qhov twg, nrog rau tej nyob rau hauv tsoom fwv, xeev, zos, tub rog thiab tribal cov tsev hais plaub? Yog tias Muaj, sau kom tas txhua qhov kev ua txhaum, thaum twg tshwm sim thiab raug nyob txim hnub twg, thiab lub nroog thiab xeev uas lub tsev hais plaub nyob. Tej zaum yuav kom koj muab lus ntxiv nrog rau ib daim ntawv txiav txim txog qhov kev ua txhaum, ib daim ntawv hais txog qhov uas tsis txaus siab txog qhov ua txhaum, los sis lwm cov ntaub ntawv los ntawm tsev hais plaub los yog tub ceev xwm.

2. Puas tau pom tias koj tau ua ib qho txhaum txoj cai los ntawm tsev hais plaub rau hnub koj lub hnub xyoog yug muaj 10 xyoo los yog tom qab ntawd? (LUS CIM: Lo lus teb rau nqe lus nug no tsuas yog nug rau cov chaw zov ib pawg los sis chaw rau tsev neeg uas zov me nyuam thiab ib qho chaw mus yos hav zoov ua si thaum nruab hnub rau me nyuam xwb.) Yog tias Muaj, sau kom tas txhua qhov kev ua txhaum, thaum twg tshwm sim thiab nyob qhov twg,, thiab lub tsev hais plaub qhov chaw (nroog thiab xeev). Tej zaum yuav kom koj muab lus ntxiv nrog rau ib daim ntawv txiav txim txog koj qhov kev ua txhaum, ib daim ntawv hais txog qhov ua txhaum, los sis lwm cov ntaub ntawv los ntawm tsev hais plaub los yog tub ceev xwm.

3. Puas tau muaj tsoom fwv los yog ib qhov chaw ua hauj lwm tswj txoj cai twg (uas tsis yog tub ceev xwm) nrhiav tau tias koj tau ua phem rau me nyuam los sis tsis saib tsis xyuas me nyuam? Yuav tau muab lus teb yog hais tias tau kos rau lub box hauv qab no: (Tsuas yog cov tswv hauj lwm thiab cov chaw ua hauj lwm tswj txoj cai uas muaj txoj cai tau txais qhov xov no raws li sec. 48.981(7) thiaj muaj cai, thiab yuav tsum tau, kos lub box no) Yog tias Muaj, piav kom meej, nrog rau qhia seb tshwm sim thaum twg thiab nyob qhov twg.

4. Puas tau muaj tsoom fwv los yog ib qhov chaw ua hauj lwm tswj txoj cai twg (uas tsis yog tub ceev xwm) nrhiav tau tias koj tau ua phem los sis tsis saib tsis xyuas ib tug neeg twg los sis tus neeg tau txais kev pab? Yog tias Muaj, piav kom meej, nrog rau qhia seb tshwm sim thaum twg thiab nyob qhov twg.

5. Puas tau muaj tsoom fwv los yog qhov chaw ua hauj lwm tswj txoj cai (uas tsis yog tub ceev xwm) nrhiav tau tias koj tau muab tej khoom ntiag tug ntawm ib us neeg nyob hauv kev pab siv yam tsis raws cai? Yog tias Muaj, piav kom meej, nrog rau qhia seb tshwm sim thaum twg thiab nyob qhov twg.

6. Puas tau muaj tsoom fwv los yog qhov chaw ua hauj lwm tswj txoj cai (uas tsis yog tub ceev xwm) nrhiav tau tias koj tau ua phem rau ib tus neeg laus? Yog tias Muaj, piav kom meej, nrog rau qhia seb tshwm sim thaum twg thiab nyob qhov twg.

7. Koj puas muaj ib daim ntawv tso cai los ntawm tsoom fwv uas tas sij hawm lawm los yog muaj kev txwv uas yuav ceev tsis tso kev dav rau koj mus muab kev pab rau cov neeg tau txais kev pab? Yog tias Muaj, piav kom meej, nrog rau muab lub npe ntawm daim ntawv tso cai, kev txwv, thiab lub sij hawm daim ntawv tas rau thaum twg.

TSHOOJ B ­ LWM COV XOV UAS KOJ YUAV TAU QHIA

MUAJ

TSIS MUAJ

1. Tsoom fwv los yog qhov chaw ua hauj lwm tswj txoj cai puas tau txwv, tsis pom zoo los sis nrho tawm koj daim ntawv pov thawj (license), ntawv lees paub, los yog ntawv sau npe muab kev pab, kev kho los yog cov kev qhia? Yog tias Muaj, piav kom meej, nrog rau qhia seb tshwm sim thaum twg thiab nyob qhov twg.

2. Tsoom fwv los yog qhov chaw ua hauj lwm tswj txoj cai puas tau tsis pom zoo tso cai rau koj los sis txwv koj tsis txhob nyob rau ntawm ib qhov chaw muab kev pab? Yog tias Muaj, piav kom meej, nrog rau qhia seb tshwm sim thaum twg thiab nyob qhov twg thiab yog vim li cas.

3. Puas tau muab koj rho tawm ntawm ib fab ntawm US Cov Tub Rog, nrog rau pab pawg uas yog npaj cia? Yog tias Muaj, muab hnub uas raug rho tawm _______________________________________ Muab ib daim qauv ntawm koj daim DD214 yog koj raug rho tawm tsis tau tshaj 3 xyoos dhau los.

4. Koj puas tau nyob tawm ntawm Wisconsin 3 lub xyoos tas los? Yog tias Muaj, sau txhua lub xeev thiab cov hnub uas koj nyob rau hauv cov xeev ntawd.

5.

Koj puas tau muaj ib qhov kev tshawb nrhiav tus neeg tu lwm tus keeb kwm yav dhau los li 4 lub xyoos tas los no? Yog tias Muaj, sau hnub uas tau tshawb nrhiav txhua txhua zaus, thiab lub npe, chaw nyob thiab xov tooj ntawm tus neeg, qhov chaw los sis tsoom fwv qhov chaw ua hauj lwm uas ua qhov tshawb nrhiav ntawd.

6. Koj puas tau thov kom muaj ib qho rov qab soj ntsuam txog kev pab kom rov peem tsheej dua (rehabilitation) nrog rau Wisconsin Department of Health Services, ib qhov chaw ua hauj lwm hauv county, ib qhov chaw ua hauj lwm txog qhov muab me nyuam mus tso, pawg tswj hwm tsev kawm ntawv, los sis qhov chaw tribe uas yog pom zoo los ntawm DHS? Yog tias Muaj, sau hnub uas rov qab soj ntsuam thiab seb qhov soj ntsuam hais li cas. Tej zaum yuav kom koj muab ib daim qauv ntawm qhov rov qab soj ntsuam kev txiav txim thiab.

Qhov teb tias "TSIS MUAJ" rau tag nrho cov lus nug tsis tau txhais hais tias yuav tau hauj lwm ua, tau chaw nyob, tau ib daim ntawv cog lus, los yog tau txais ib qho kev tso cai. Kuv nkag siab, raws li kev ua txhaum cai, tias txhua yam kuv muab hais los saud yeej muaj tseeb thiab yog raws li qhov kuv paub zoo thiab paub tias kev muab lus dag los yog qhia tsis tas yuav raug them txog li ntawm $1,000.00 thiab lwm cov kev nplua uas muaj nyob rau hauv DHS 12.05 (4), Wis. Adm. Code.

KOS NPE Hnub Kos Npe

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