New Applicant Background Check Process

DQA is required to complete caregiver background checks on:

• License Holders / Legal Representatives

  Individuals who apply for regulatory approval to operate any entity regulated by DQA must submit a Background Information Disclosure (BID) form and BID Appendix whether or not the person has regular, direct contact with clients.

  NOTE: If the owner is a corporation or other type of business that does not have a single owner, such as (but not limited to):

  • domestic corporation
  • non-stock corporation
  • partnership
  • limited liability company

  then the organization must designate a representative to legally represent the organization for the purposes of fulfilling the background check requirements.

• Principal officers, corporation or board members of the business organization if they have regular, direct contact with clients.

• Nonclient residents – Individuals age 10 and older who are not clients but who reside at the entity if they have regular, direct contact with clients.

As the license holder / legal representative, you should ensure that you, your board members (with client contact) and your nonclient residents (10 and older with client contact):

1. Complete a Background Information Disclosure (BID) form, F82064 (PDF, 30 KB).
2. Complete a Background Information Disclosure Appendix form, F82069 (PDF, 31 KB).
3. Include a $10.00 processing fee for each person, payable to "Division of Quality Assurance."  The fee is required* for an initial application.
4. Submit all forms with appropriate fee to:

Entity Background Checks
Department of Health Services
Division of Quality Assurance
Office of Caregiver Quality
PO Box 2969
Madison, WI 53701-2969

Fee exemption – If you are the license holder/legal representative of an existing facility and are completing an application for a new license, registration or certification, you must complete both forms with the new facility information but you may omit the fee.

• DQA will contact you if the fee is required. If you are unsure if you meet this exemption, please include the fee. It will be returned to you if our records indicate it is not necessary.

NOTE: Please only submit the forms for the license holder, board members and nonclient residents to DQA. Refer to Chapter 3 of The Wisconsin Caregiver Program Manual (PDF, 26 KB) for more information.

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Last Revised: July 08, 2009