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Richland Hospital

Job Shadow Program

333 East Second StRichland Center, WI 53581608-647-6321888-467-7485 Toll-free

www.richlandhospital.com

Richland Hospital Job Shadow ProgramJob shadowing at the Richland Hospital is a great way to get a “behind-the-scenes” look at the daily responsibilities of local professionals in the health care field. In providing these opportunities, we hope you gain valuable insight about professions that interest you and other jobs that interact with the person that you are job shadowing.

To participate in our Job Shadow Program, you will need to review the contents of this packet carefully. Then, complete and sign the forms included, take the short quiz and return them to the Richland Hospital a minimum of two weeks prior to the time you wish to job shadow.

The forms inside require your signature in many different places. By signing your name, you signify that you understand and agree to the information on each sheet.

For more information or to get your questions answered, please contact:

Ellie StanekQuality & Education Coordinator

The Richland Hospital, Inc.333 East Second StreetRichland Center, WI 53581608-647-6321

Thank youThank you for

your interest

in job shadowing

at Richland Hospital.

This job shadow program

holds true to our mission:

The Richland Hospital

is dedicated to caring,

educating, and healing…

striving to be the

community’s

“First Choice for

Better Health.”

Job Shadow Program– 3TRH_011EB-1017 The Richland Hospital, Inc. 608-647-6321

Policies, Procedures & Health and Safety InformationDRESS CODE

The appearance of Richland Hospital Job Shadow participants directly correlates with our patients’ percep-tions of our professionalism, competency and quality of care/services. All job shadow participants must adhere to the following guidelines. The Richland Hospital Job Shadow Mentor reserves the right to dismiss a Job Shadow participant if their appearance is inappropriate or offensive to staff or patients.

• Nametags stating you are job shadowing must be worn visibly on the front of outer garments.

• Hair must be clean and neat.

• Personal Hygiene is important. Each job shadow candidate is expected to maintain good grooming habits and hygiene to prevent body odor/bad breath.

• Perfume, cologne, or other fragrance substances will not be worn.

• Clothing must be neat, clean, in good condition and properly fitting. Tight clothing, low cut blouses or clothing that allows undergarments to show through may not be worn. Dress/skirt/dress shorts/skorts should be of moderate length. Blue jeans are not allowed.

• Hose/Socks/Shoes must be worn at all times and cover any exposed leg area. Closed-toed shoes must be worn. Shoes should be kept clean, in good condition, and reflect the needs of the work performed.

• Accessories: All visible jewelry, including those for piercings, must be minimal and unobtrusive. Earrings, necklaces, rings etc. may he worn in moderation. Safety and patient care should be considered when determining whether jewelry/accessories may be worn.

• Hats will not be worn indoors.

• No chewing gum is allowed during patient contact.

FIRE SAFETY (CODE RED)

R. A. C. E. IF you discover fire/smoke.

R Rescue those persons in immediate life-threatening dangerA Announce & Activate: Pull the nearest fire alarmC Confine the fireE Extinguish or Evacuate

• If you are NOT in the area of the fire: stay where you are and listen for further instructions.• You do not have a specific role during a fire event; follow instructions provided by your mentor or the unit charge person.

• If you discover a fire, notify a staff member immediately.


ELECTRONIC DEVICES

Electronic devices including, but not limited to cell phones, iPods, iPads, tablets, and pagers may not be used during the job shadow experience and should not be carried with you.

HAND WASHING

Hand washing is the single most important measure in the prevention and transmission of infection(s). Failure to wash hands correctly and in a timely manner is an infection control hazard. Hand washing must occur:

• Before, after and between patient contacts.

• Before and after glove use.

• Immediately, if anticipated contact with body substances occurs (thorough washing with soap and water is to be done as soon as possible).

• Anytime when indicated to prevent transfer of microorganisms (i.e., before and after eating, after cough-ing, sneezing, blowing one’s nose, using the bathroom, etc.).

Hand washing Procedure…vigorous washing for at least 20 seconds.

• Wet hands thoroughly with warm running water.

• Soap hands working up a lather using friction and rotating motion to clean around the nails, fingers, palms, backs and sides of hands for 20 seconds.

• Rinse hands well keeping hands lower than elbows.

• Dry hands using clean paper towels; discard and,

• Turn off faucets using paper towels and discard in regular waste basket. Consider the entire sink as contaminated.

• Apply hand lotion if desired to protect integrity of the skin.

BLOOD BORNE PATHOGENS EXPOSURE CONTROL

Blood borne pathogens are viruses, bacteria and other microorganisms that:

• are “borne” or carried in a person’s bloodstream,

• cause disease.

If a person comes in contact with blood infected with a blood borne pathogen, he or she may become infected as well.

To prevent and minimize exposure to blood and other potentially infectious materials, engineered equipment, work practice polices and procedures and personal protective equipment (PPE) are utilized. If you are asked to use any of this equipment make sure you are shown how to use it.


BLOOD/BODY FLUID EXPOSURE

A blood/body fluid exposure is an unprotected exposure or protective failure in which one is exposed to another person’s blood or body fluid. Examples include, but are not limited to, puncture with a contaminated needle or sharp, splash or splatter from blood or body fluids into a mucous membrane or open skin lesion or break in gloves exposing to blood or body fluids.

In the event of a blood/body fluid exposure…

• Wash the contaminated area thoroughly with soap and water for a minimum of 5 minutes; if the exposure is to the eye(s), use an eye wash station (located in Emergency Dept.) and irrigate the eye(s) for a minimum of 15 minutes.

• Complete a Notification (Accident) Report Form; staff in the area can assist you.

• Report to Employee Health or the Nursing Clinical Coordinator immediately for appropriate assessment, treatment and follow up.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

PPE provides a protective barrier and reduces the likelihood of transmission of micro-organisms. PPE includes, but is not limited to, gloves, gowns, masks and protective eyewear.

Gloves are to be worn for…

• Direct contact with mucous membranes or non-intact skin of any patient, when handling specimens or when handling equipment/wastes potentially contaminated with body fluids.

• Anticipated contact with any patient’s blood, pus, feces, urine, oral secretions or any other body fluid as specified by specific isolation precaution guidelines.

• Gloves are to be changed between different procedures on the same patient and between patient con-tacts. Hands must be washed each time gloves are removed; use of a hand sanitizer is also acceptable.

Gowns are to be worn whenever…

• It is anticipated that personal clothing will be soiled with any patient’s body fluids.

• Contact with contaminated items and as specified by specific isolation precaution guidelines.

Face protection is to be worn…

• To protect the mucous membranes of the eyes, nose and mouth during procedures.

• If patient care activities that are likely to generate splashes, splatters or sprays of blood, body fluids, secretions or excretions.


Patient Privacy & Confidentiality HIPAAThe Richland Hospital, Inc. and its workforce are dedicated to safeguarding and maintaining the confiden-tiality, integrity, and availability of our patient, employee, and organizational information (collectively here-in after “Privileged Information”). “Privileged Information” includes, but is not limited to: HIPAA and state-law Protected Health Information (PHI)1, information regarding patient visits, medical records, telephone/cell phone messages, faxes, e-mails, statements, insurance claims, contracts, computer documentation and other electronic media, provider schedules, quality data, peer review and business practice information, personal records, and other medical, personal, insurance, business, or financial information. Protection of PHI extends to information in any form, including written, verbal, or electronic data.

Maintaining confidentiality of patient information involves anyone connected with the hospital, from the Board of Directors, to the occasional employee, and to each volunteer. Everyone is ethically bound not to divulge information of a confidential or private nature.

At The Richland Hospital, Inc. it is our policy to treat patient information of any nature as confidential. This includes information from or about medical records, test results, appointments, referrals, and billing infor-mation.

It is our obligation to make sure that medical information is not disclosed inappropriately, accidentally, or negligently. If either of the three occur, it is considered a breach of confidentiality, and may be punishable under State and now Federal laws, depending on the nature of the breach. Worse than this would be the loss of the trust that our patients have in us. Put yourself in the patient’s place; would you come here if you knew that everyone would know why?

A breach due to carelessness is any unintentional or careless access of patient information without a legit-imate need to know. Examples include discussion of patient information in a public area, leaving a copy of a medical document in a public area, leaving a computer terminal unattended in an accessible area with a medi-cal record unsecured or not “parked.”

A breach due to curiosity (no personal gain from the information) occurs when an employee or associate intentionally accesses or discusses patient information for purposes other than the care of the patient or other authorized purposes. Examples include but are not limited to looking up birth dates or addresses of friends or relatives, reviewing the record of a patient out of concern or curiosity, reviewing a public personality’s record out of curiosity.

A breach for personal gain or out of malice occurs when an employee or associate accesses, reviews or discusses patient information for personal gain or with malicious intent. Examples include but are not limited to reviewing a patient record to use information in a personal relationship, or compiling a mailing list for personal use or to be sold.

A few tips to avoid problems:

• Remember that conversations can be overheard. Private conversations should be held in private plac-es.

• Speak softly over the telephone and try to avoid excessive use of the patient’s name.• Use confidential trash bins when disposing of documents containing any medical or patient identifi-

able information.• Do not allow medical information on terminals to be visible to patients and passers by.• Do not discuss patient information with anyone in a social conversation, not here, not anywhere.• If anyone asks you for information about a patient, politely respond, “That information is confidential.”


Patient Privacy & Confidentiality HIPAA – AgreementAS A JOB SHADOW CANDIDATE, I AGREE THAT I WILL:

• Treat all Privileged Information as confidential and sensitive.

• Never use tools or techniques to attempt to violate or exploit security measures.

• Immediately report to the Compliance Officer or HIPAA Security Officer an activity that violates this agreement, HIPAA or associated State legislation, or any other incident that could have any adverse impact on Privileged Information.

• Upon completion of my job shadow experience, I will continue to maintain the confidentiality of any information I learned while job shadowing and agree to turn over any, access cards (badges), or any other device that would provide access to The Richland Hospital, Inc. or its Information Systems.

AS A JOB SHADOW CANDIDATE, I AGREE THAT I WILL NOT:

• Disclose Privileged Information to any person or entity.

• Access, review or receive copies of any medical information about myself or any member of my family.

• In any way divulge copy, release, sell, loan, alter, or destroy any Privileged Information.

• Download any PHI from The Richland Hospital, Inc. information systems to removable storage media for any purpose.

• Use information systems to transmit, retrieve, nor store any communication containing any discriminatory, harassing, obscene, solicitous, or illegal information.

My signature acknowledges that I have read and understand this document. Further, this Agreement will be enforced to the extent permissible by law & continues after completion of this job shadowing experi-ence. I have had the opportunity to discuss this Agreement with Human Resources, my mentor or desig-nee and all my questions have been answered to my satisfaction.

Signature _____________________________________________ Date ___________________________ (Job Shadow Candidate)

(If under 18 years of age, please have a sponsor reference complete page 13)


Job Shadow Application – Medical ScreeningPERSONAL HEALTH HISTORY

1. List any chronic health problems or immune disorders ______________________________________

______________________________________________________________________________ (None)

2. List any allergies _____________________________________________________________________

______________________________________________________________________________ (None)

3. Describe any chronic skin conditions or open wounds _______________________________________

______________________________________________________________________________ (None)

4. Have you ever had chicken pox? Yes No

5. Have you ever had the chicken pox vaccine? Yes No

Please attach a copy of your immunization records from your physician office or state database, such as the Wisconsin Immunization Registry. You can access this by going to:http://www.dhs.wisconsin.gov/immunization/publicaccess.htm

Measles, Mumps, Rubella (MMR) __________________ __________________ (Required)

Tdap/Tetanus __________________ (within the past 10 years)

Hepatitis B __________________ __________________ ___________________

Varicella (chicken pox) or documented history of chicken pox _______________ ___________________

Seasonal Influenza (Flu) Vaccine __________________ (October-April)

A seasonal influenza (Flu) vaccine is required for job shadowing during the months of October through April or at the discretion of The Richland Hospital, Inc.

TB Skin Test __________________

If requesting to job shadow for greater than 1 day, documentation of a TB skin test within the past 12 months is required. Please attach documentation to packet.

I certify that the foregoing health history statements are true and complete.

Signature ____________________________________________________ Date ___________________

Parent/Guardian Signature _______________________________________ Date ___________________

The Richland Hospital, Inc.333 East Second StreetRichland Center, WI 53581608 647-6321888 467-7485 toll free

Muscoda Health Center1075 North Wisconsin AvenuePO Box 657Muscoda, WI 53573608 739-3113

Spring Green Medical Center150 East Jefferson StreetPO Box 10Spring Green, WI 53588608 588-7413


The Richland Hospital, Inc.

Muscoda Health CenterSpring Green Medical Center

Divisions of The Richland Hospital, Inc.

Employee Health TB Screening From: Rachel Fruit, RN

RE: TB Screening

If requesting to job shadow for greater than 1 day, documentation of a TB Skin Test is required.

PLEASE READ AND ANSWER THE FOLLOWING QUESTIONS

1. Have you had a productive cough for greater than 3 weeks? Yes No

2. Have you had persistent weight loss without dieting? Yes No

3. Do you have a persistent low grade fever? Yes No

4. Do you experience night sweats? Yes No

5. Do you have a loss of appetite? Yes No

6. Do you have swollen glands, usually in the neck? Yes No

7. Do you have recurrent kidney or bladder infections? Yes No

8. Do you cough up blood? Yes No

9. Do you experience shortness of breath? Yes No

10. Do you experience chest pain? Yes No

11. In the past 5 years, have you lived or traveled in Africa, Asia,

Central America, South America, Mexico, Eastern Europe,

Caribbean, or the Middle East for more than one month? Yes No

12. Have you ever had a positive TB skin test? Yes No

Thank you. I will contact you if you need further TB testing.

_____________________________________________________________ ___________________________Signature/Parental signature required if under 18

TRH_011EB-1017


Applicant Information

Name ___________________________________________ Date of Birth ________________ Age ________

Address ________________________________________________________________________________

City, State, Zip ___________________________________________________________________________

Phone ____________________________ Email _______________________________________________

Emergency Contact Name _________________________________ Relationship _____________________

Primary Phone Number___________________________Secondary Phone Number ___________________

(If Applicable)

School ______________________________________ Year in School ______________________________

Teacher to Contact _____________________________ Phone ____________________________________

Department, area, or person that you are interested in Job Shadowing

1st Choice __________________________________ 3rd Choice _________________________________

2nd Choice __________________________________

Length of time you are requesting to job shadow (number of hours/visits) __________________________

Preferred Time & Day to Job Shadow

Job Shadow – High School

Job Shadow – College

Job Shadow – Adult

Unpaid Internship

School to Work Program

Career Change Exploration

Other ____________________ ____________________________

Job Shadow ApplicationALL APPLICANTS MUST COMPLETE THE ATTACHED BACKGROUND INFORMATION DISCLOSURE

Morning

Monday

Friday

Afternoon

Tuesday

Saturday

Evening

Wednesday

Sunday

Thursday

Please list or describe any concerns you may have about job shadowing

________________________________________________________________________________________

________________________________________________________________________________________

Please explain why you would like to job shadow, including any learning or career goals

________________________________________________________________________________________

________________________________________________________________________________________


Job Shadow Application – Quiz (100% Required)

To ensure that our job-shadow students understand key safety information, we have developed the fol-lowing quiz. After reading the educational materials for job-shadowing students found in this packet, you should be able to complete this short quiz.

PLEASE CIRCLE THE CORRECT ANSWERS

1. It is a breach of confidentiality if I go home and tell my family that our neighbor, who is a close friend, is being hospitalized.

True False

2. It is a breach of confidentiality if I write a report about a patient I observed after my job shadow for a class project.

True False

3. It is a breach of confidentiality if I read the diagnosis, treatment, test results, financial, or other information on a patient’s chart.

True False

4. Hand washing is the most important procedure for controlling infection. True False

5. I should wash my hands frequently, especially after using the restroom, sneezing, touching my hair, face, shoes, and before leaving for home.

True False

6. Blood borne pathogens are viruses, bacteria or other microorganisms that are carried in the bloodstream that can cause disease.

True False

7. I should cover cuts, scrapes, hangnails, rashes, etc. while job shadowing and wear personal protective equipment if I feel uncomfortable with my level of protection in a patient care area.

True False

8. While I am job shadowing, I should wear clothing that is comfortable, yet neat and clean, and I should present a professional appearance.

True False


Job Shadow Agreement I. I, _____________________________________ , have requested, and The Richland Hospital, Inc.

hereby grants, the afore mentioned, permission to be present in the hospital or rural health clinic setting for observation to enhance my education.

In return, I, the Job Shadow Participant, agree to adhere to the following rules:

A. Present this signed and completed application prior to the job shadowing experience (if a mi-nor, a parent or legal guardian’s signature is mandatory);

B. Follow good hand-washing techniques;

C. Adhere to the job shadow dress code;

D. Wear personal protective equipment if there is a potential of contacting blood or other body fluids;

E. Wear a name tag identifying myself as a Job Shadow student;

F. Inform my mentor if at any time I feel nauseous, dizzy or otherwise ill during the shadowing activity;

G. Arrive promptly and remain flexible to allow for extenuating circumstances such as patient emergencies that might interrupt the schedule;

H. Remain at all times where directed and leave the areas when requested to do so by a physician, nurse, or administration; and

I. At the conclusion of my assignment, complete an evaluation of the program and return it to my mentor.

II. I understand the patient’s right to confidentiality and agree to respect that right by not disclosing information regarding any patient or regarding the organization/administration.

III. I recognize that observing in the healthcare setting and any complication thereof may be emotion-ally distressing. I also recognize the primary responsibility of the physicians and personnel is to the patient; therefore, it may not be possible to provide immediate attention to me should the need arise.

IV. I understand this permission granted may be revoked at any time during the job shadow experience by the attending physician or other staff.

V. In consideration of the permission granted, I hereby release the physicians, the organization, and its employees from any claims or liability, physical injury and/or damage including emotional distress or injury or mental anguish which may be sustained by me or the patient as a result of the presence of myself in the hospital or rural health clinic.

VI. I am age 16 or older.

Signature______________________________________________________ Date ___________________

Signature of Parent/Guardian, if under 18 ____________________________ Date ___________________

(If under 18 years of age, please have a sponsor reference complete page 13)

(Job Shadow Candidate)


Sponsor Reference for Job Shadow Applicant

A sponsor is a person in a leadership position who is a mentor to the job shadow applicant. This includes, but is not limited to, a teacher, healthcare worker, pastor or coach. The sponsor must fill out this form for the job shadow applicant.

_______________________________________________________________________________________(Job Shadow Person Name)

Sponsor Name (please print) _______________________________________________________________

Relationship to applicant __________________________________________________________________

How long have you known this person? ______________________________________________________

Why would this person be a good candidate for job shadowing in a healthcare setting? _______________

________________________________________________________________________________________

________________________________________________________________________________________

Do you have any concerns with this student job shadowing? ______________________________________

________________________________________________________________________________________

________________________________________________________________________________________

If you were the patient, would you be comfortable with the student’s ability to protect your privacy and confidentiality? ___________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

CONTACT INFORMATION

Phone _________________________________________________________________________________

Best time to contact _____________________________________________________________________

Email __________________________________________________________________________________

I have discussed with and agree to be a sponsor for the above student. I certify that this student would be an appropriate candidate for job shadowing.

Signature ____________________________________________________ Date _____________________

The Richland Hospital, Inc.333 East Second StreetRichland Center, WI 53581608 647-6321888 467-7485 toll free

Muscoda Health Center1075 North Wisconsin AvenuePO Box 657Muscoda, WI 53573608 739-3113

Spring Green Medical Center150 East Jefferson StreetPO Box 10Spring Green, WI 53588608 588-7413


The Richland Hospital, Inc.

Muscoda Health CenterSpring Green Medical Center

Divisions of The Richland Hospital, Inc.

Job Shadow / Healthcare Student Checklist ( IN HOUSE USE ONLY ) Name ____________________________________________________________________________________

Department _______________________________________________________________________________

Date _____________________________________________________________________________________

TASK JOB SHADOW HEALTHCARE STUDENTS

HIPAA review/signature

Job Shadow Packet complete/ signed (RHI Website/Intranet)

Contract with University on file (HR)

TB Skin Test/Screening

Required Immunizations

MMRTetanusHep BVaricella

Influenza Vaccine (October – April)

Background Check

Clinical Competency Checklist

Clinical Preceptor/ Department Head approval

Sponsor Reference

TRH_011EB-1017

DEPARTMENT OF HEAL TH SERVICES Division of Enterprise Services F-82064A (02/2014)

STATE OF WISCONSIN Chapters 48.685 and 50.065, Wis. Stats.

OHS 12.05(4), Wis. Admin. Code

BACKGROUND INFORMATION DISCLOSURE (BID) INSTRUCTIONS

The Background Information Disclosure form (F-82064) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment , contract , residency , and regulatory decisions . Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency. NOTE: If you are an owner , operator , board member , or non-client resident of a Division of Quality Assurance (DOA) facil ity , complete the BID, F-82064 , and the Appendix, F-82069, and submit both forms to the address noted in the Appendix Instructions.

CAREGIVER BACKGROUND CHECK LAW In accordance with the provisions of Chapters 48.685 and 50.065 , Wis . Stats ., for persons who have been convicted of certain acts , crimes , or offenses :

1. The Department of Health Services (OHS) may not license , certify , or register the person or ent ity (Note: Employers and Care Providers are referred to as "entities ");

2. A county agency may not certify a child care or license a foster or treatment foster home ; 3. A child placing agency may not license a foster or treatment foster home or cont ract with an adoptive parent applicant for a child

adoption ; 4 . A school board may not contract with a licensed child care provider ; and 5. An entity may not employ , contract with or, permit persons to reside at the entity.

The list of offenses affecting caregiver eligibility that require rehabilitation review is available from the regulatory agencies or through the Internet at http ://DHS wiscons1n.qov/caregiver/Statu tes lNDEX.HTM.

THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS I CARE PROVIDERS (Referred to as "Entities"):

Programs Regulated under

Chapter 48, Wis. Stats.

Programs Regulated under

Chapters 50, 51, and 146, Wis.

Stats.

Others

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.

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 - including those that provide personal care services.

Child Care Providers contracted through Local School Boards

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS:

• Anyone employed by or contracting with a covered entity who has access to the cl ients served , except if the access is infreque nt or sporadic and service is not directly related to care of the client. Exception : Emergenc y medical technicians and first responders are not covered under the Caregiver Law.

• Anyone who is a Child Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14) . • Anyone who lives on the premises of a covered entity and is 10 years old or over , but is not a client ("non-client resident") . • Anyone who is licensed by OHS. • Anyone who has a foster home licensed by OHS. • Anyone certified by OHS. • Anyone who is a Child Care Provider certified by a county department . • Anyone registered by OHS. • Anyone who is a board member or corporate officer who has access to the clients served .

FAIR EMPLOYMENT ACT Wisconsin 's Fair Employment Law, Chapters 111.31 - 111.395, Wis . Stats ., prohibits discrimination because of a criminal record or pending charge ; however , it is not discrimination to decline to hire or license a person based on the person 's arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity.

PERSONALLY IDENTIFIABLE INFORMATION This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary ; however , your socia l security number is one of the unique identifiers used to prevent incorre ct matches . For examp le, the Department of Justice uses social securi ty numbers . names, gender , race , and date of birth to prevent incorrect match es of persons with criminal convictions. The Department of Health Services ' Caregiver Misconduct Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misapprop riation of a client's property .

DEPARTMENT OF HEAL TH SERVICES Division of Enterprise Services

STATE OF WISCONSIN Chapters 48.685 and 50 065, Wis. Stats.

F-82064 (02/2014 ) OHS 12.05(4), Wis. Admin. Code

BACKGROUND INFORMATION DISCLOSURE (BID) Completion of this form is required under the provisions of Chapters 48 .685 and 50 .065 , Wis . Stats . 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. Refer to the instructions (F-82064A) on page 1 for additional information . Providing your social security number is voluntary ; however . your social security number is one of the unique identifiers used to prevent incorrect matches .

PLEASE PRINT OR TYPE YOUR ANSWERS.

Check the box that applies to you. D Employee I Contractor (including new applicant)

D Applicant for a license or certification or registration (including continuation or renewal)

D Household member I lives on premises - but not a client

D Other - Specify :

NOTE: If you are an owner , operator , board member , or non-client resident of a Division of Quality Assurance (DOA) facility , complete the BID, F-82064 , and the Appendix . F-82069, and submit both forms to the address noted in the Appendix Instructions .

Name - (First and Middle) Name - (Last) Position Title (Complete only if you are a prospective employee or contractor, or a current employee or contractor.)

Any Other Names By Which You Have Been Known (Including Maiden Name) Birth Date I Gender (M I F\

Race Social Security Number(s) O American Indian or Alaskan Native O Black D Unknown O Asian or Pacific Islander 0White Home Address I City State I Zip Code

Business Name and Address - Employer or Care Provider (Entity)

SECTION A-ACTS, CRIMES, AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION YES NO

1. Do you have any criminal charges pending against you or 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 . D D

2. Were you ever found to be (adjudicated) delinquent by a court of law on or after your 101h birthday for a crime or

offense? (NOTE : A response to this question is only required for group and family day care centers for children and day camps for children .) ~ If Yes, list each crime . 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 D D adjudication , or any other relevant court or police documents .

3. Has any government or regulatory agency (other than the police ) ever found that you committed child abuse or neglect? A response is required if the box below is checked :

0 (Only employers and regulatory agencies entitled to obtain this information per sec. 48 .981 (7) are authorized to , and should , check this box .)

~ If Yes. explain , including when and where it happened . D D

F-82064 Page 2 of 3

Last Name-

SECTION A-ACTS, CRIMES , AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION YES NO

4. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? ~ If Yes, explain , including when and where it happened .

D D

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? ~ If Yes , explain , including when and where it happened .

D D

6. Has any government or regulatory agency (other than the police ) ever found that you abused an elderly person? ~ If Yes, explain , including when and where it happened .

D D

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?

~ If Yes , explain , including credential name , limitations or restrictions , and time period . D D

SECTION 8- OTHER REQUIRED INFORMATION YES NO

1. Has any government or regulatory agency ever limited , denied , or revoked your license , certification , or registration to prov ide care , treatment , or educational services ? ~ If Yes, explain , including when and where it happened .

D D

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 ? ~ If Yes, explain , including when and where it happened and the reason . D D

3. Have you been discharged from a branch of the US Armed Forces , including any reserve component ?

~ If yes , indicate the year of discharge : __

~ Attach a copy of your DD214 if you were discharged within the last 3 years . D D

4. Have you resided outside of Wisconsin in the last 3 years ? ~ If Yes , list each state and the dates you lived there .

D D

F-82064 Page 3 of 3

Last Name-

SECTION B - OTHER REQUIRED INFORMATION YES NO

5. Have you had a caregiver background check done within the last 4 years? J;,, 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 . D D

6. 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? J;,, If Yes , list the review date and the review result. You may be asked to provide a copy of the review decision . D D

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 and that knowingly providing false information or omitting information may result in a forfeiture of up to $1 ,000 .00 and other sanctions as provided in DHS 12.05 (4), Wis . Adm . Code .

SIGNATURE Date Signed

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