Background Check Forms

ALL PROGRAMS

Caregiver Background Checks:

Background Information Disclosure and Instructions (BID)

• English - Information Disclosure and Instructions, (PDF, 46 KB), HFS-64 

• Hmong - DAIM NTAWV QHIA MOJ KAB SIM TXOG KEEB KWM/LUS QHIA UA TXOG DAIM NTAWV QHIA TAWM TXOG KEEB KWM, (PDF, 50 KB), HFS-64H

• Spanish - Divulgacion de Informacion de Antecedentes/Instrucciones, (PDF, 49 KB), HFS-64S

Click on Wisconsin Department of Justice (exit DHFS) to access the following forms and instructions for completing them:

• Wisconsin Criminal History Single Name Record Request Form DJ-LE-250

• Wisconsin Criminal History Multiple Name Record Request Form DJ-LE-250A

• Wisconsin Criminal History Account Application Form DJ-LE-251

Health Care Providers Only: DQA Regulated Entity Background Check Process

Rehabilitation Review:

• Click on Rehabilitation Review Request Instructions and Form (PDF 42 KB), EXS-263, if you are a caregiver required pursuant to Ch. HFS 12 (exit DHFS; PDF 40 KB) to prove rehabilitation.

• Counties, school boards, child placing agencies and tribes may order the forms to report rehabilitation review panel decisions to the Department of Health and Family Services. See Ordering Printed Forms for the following:

  • Rehabilitation Review Panel Decision Report, EXS 264

  • Instructions for Rehab Review Panel Decision Report, EXS 264A

  • Rehabilitation Review Appeals Report, EXS 265

  • Instructions for Rehab Review Appeals Report, EXS 265A

Children's Programs 
regulated by the Division of Children and Family Services

Children's Programs HFS 12 Negative Action Notice form (PDF, 10 KB), CFS-2191

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Last Revised: June 30, 2008