Free Rehabilitation Review Application, F-83263 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

REHABILITATION REVIEW APPLICATION INSTRUCTIONS The Rehabilitation Review Application consists of eight sections. You are required to complete each of these sections. Pursuant to section HFS 12.12(4)(b), Wis. Admin. Code, failure to complete the application and provide the requested documentation within 90 days of the date your application is submitted to the rehabilitation review agency may result in a denial of your request for rehabilitation approval. Pursuant to HFS 12.12(2)(a), Wis. Admin. Code, if your application is denied, you may not apply for rehabilitation review again for the same or similar reason for one year from the date of your denial. Your social security number is requested so that it may be used as one of the unique identifiers to prevent incorrect matches with persons with criminal convictions or findings of abuse or neglect of a person or client or misappropriation of a client's property. You are not required to provide your social security number. However, failure to provide your correct social security number may result in incorrect matches. The information and materials you submit may be used for purposes other than the rehabilitation review process and are subject to Wisconsin's open records laws. Specific instructions on how to complete the application are included in each section. If you need help in completing the application, call the Office of Legal Counsel at 608-266-8428. You may be asked to provide additional information and documents not requested in the application. A Rehabilitation Review Panel consisting of two or more persons will meet to discuss your application materials and make a decision of whether to approve or deny your request for rehabilitation approval. You will be notified by mail when and where the Rehabilitation Review Panel will meet. Although you are not required to appear at the rehabilitation review panel meeting, your appearance is recommended. The Panel may ask you questions to help in their decision. A decision may be deferred up to 6 months to gather additional information or for other reasons. The Panel will issue a written decision. · · If the Review Panel finds sufficient evidence of rehabilitation, the decision may specify any conditions or limitations that are imposed. If the Review Panel does not find sufficient evidence of rehabilitation, the decision will provide the reasons for denial and inform you of your right to file an appeal.

Decisions of the Review Panel will be sent to the person requesting the review and, as applicable or requested, to the facility, regulatory authority or program in which the requestor is seeking to work, operate or live as a nonclient resident. A rehabilitation approval does not ensure that you will receive employment, regulatory approval, contracts, or permission to reside at an entity. Each application is handled on a case by case basis. Mailing Instructions: See Section I on the attached Rehabilitation Review Application.

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

REHABILITATION REVIEW APPLICATION
Completion of this application form and providing requested documentation is required under the provisions of sections 48.685 and 50.065 of the Wisconsin Statutes, and Chapter HFS 12, Wisconsin Administrative Code. Failure to complete this form and provide the requested documentation within 90 days of the date your application is submitted may result in a denial of your request for rehabilitation approval. For help in completing this form read the instructions found in each section of this application or call the Office of Legal Counsel at 608-266-8428. SECTION A ­ APPLICANT INFORMATION
Name of Applicant (include maiden name, any aliases, and nicknames) Social Security Number Gender Female Male

Birthdate Month

Day

Year

Birth Place County

State

Country

If under age 18 ­ Name, Address and Telephone Number of Parent, Guardian or Legal Representative

Permanent Address

Area Code / Telephone Number

City

State

Zip Code

County

Current Mailing Address (if different than above)

City

State

Zip Code

County

SECTION B ­ ENTITY AND APPLICANT TYPE 1. Check the box(es) that most closely matches the reason(s) you are applying for Rehabilitation Review. (Check all that apply) Maintain Current Employment Maintain Current Licensure Maintain Current Non-Client Residency Maintain Current Contract(s) Maintain Current Foster Parent Licensure Maintain Current Student Clinical Applicant for Employment Applicant for Licensure Applicant for Non-Client Residency Applicant for Contract(s) Applicant for Foster Parent Licensure Applicant for Adoption Home Study

2

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (3/01)

STATE OF WISCONSIN

2. Check the box(es) that most closely matches the type of entity for which you will be employed, licensed, contracted with, or a non-client resident. (Check all that apply) Hospitals Mental Health Day Treatment Services for Children (Including medical clinics that are part of the hospital) Nursing Homes Community Support Programs Hospices (CSP's ­ mental health services) Rural Medical Centers Family Foster Homes / Treatment Foster Care Community Based Residential Facilities Foster Home-Adoption (CBRFs / Group Homes) Group Foster Homes for Children Community Mental Health, Developmental Disabilities and State Licensed Family Day Care Centers Alcohol and Other Drug Abuse services County Certified Day Care Centers State Licensed Home Health Agencies Group Day Care Centers Facilities for the Developmentally Disabled Child Day Care Contracted by School Boards Residential Care Apartment Complexes Residential Care Centers for Children & Youth (RCAC / Assisted Living Facilities) Shelter Care Facilities for Children 3 and 4 Bed Adult Family Homes Child Placing Agencies Emergency Mental Health Services Programs Day Camps for Children Ambulance Service Providers 3. Write a summary of the responsibilities you currently have, or will have, at the entity type(s) you selected above. Be sure to include your job title, the type or amount of supervision you have, or will have, and the name, address and telephone number of the entity. Please also indicate whether the entity serves clients under 18 years old.

3

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-8363 (7/08)

STATE OF WISCONSIN

SECTION C ­ INFORMATION ABOUT OFFENSES 1. List below each crime or offense for which you were convicted. Attach and initial additional sheet(s) if necessary, continuing case codes in alphabetical order.
Case Code Name of Crime or Offense Conviction Date Sentence Location of Court where Convicted (City, County, State)

a.

b.

c.

d.

e.

f.

g.

h.

i.

4

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

YES

NO

2. For any of the crimes or offenses you listed on page 4, have you ever been ordered by a court, employer, or agency to receive counseling or therapy, assessments, or to participate in treatment programs for violence, aggression, parenting, anger management, sex offender issues, alcohol or other drug abuse, or for any other reason? If Yes, provide the case code(s) below, and check all that apply.
Case Code Insert Case Code from Page 4 Case Code Case Code Case Code Case Code Case Code Case Code Case Code

þ

a. Ordered to Receive: (Check all that apply)

Assessment Counseling Therapy Treatment Program Other ­ Specify:

b. For the following Behavior Area(s): (Check all that apply)

Aggression Alcohol / Other Drug Abuse Anger Management Parenting Sex Offender Issues Violence Other ­ Specify:

c. Not ordered to receive any of the above
YES NO

3. For any of the crimes or offenses listed on page 4, have you ever requested clemency (pardon, commutation of sentence or a reprieve)? If Yes, in the space provided, indicate the case code(s) from page 4, and the date of the request. Case Code Month / Year

YES

NO

4. Are there any pending criminal charges against you? If Yes, in the space provided, state the name of the offense / charge; date you were arrested or charged; and the city, county and state in which you were charged. Also attach to this application a copy of the criminal complaint. Name of Offense / Charge Month / Year City / County / State

5

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

5. List any crimes or offenses for which you were arrested, but not convicted; date you were arrested and the city, county and state in which you were arrested. Attach and initial additional sheet(s) if necessary. Name of Crime / Reasons for Arrest Date of Arrest City / County / State

YES

NO

6. Are you the subject of any current investigations by a government or regulatory agency (other than the police)? If Yes, in the space provided, state the name of the government agency conducting the investigation; the investigation date; reasons for the investigation; and the city, county and state within which the investigation is being conducted. Attach and initial additional sheet(s) if necessary. Name of Agency Month / Year Reasons for Investigation City / County / State

YES

NO

7. Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? If Yes, in the space provided, state the name of the agency; the date; and the city, county and state where the incident occurred. Attach and initial additional sheet(s) if necessary. Name of Agency Month / Year City / County / State

YES

NO

8. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client? If Yes, in the space provided, state the name of the agency; the date; and the city, county and state where the incident occurred. Attach and initial additional sheet(s) if necessary. Name of Agency Month / Year City / County / State

6

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

YES

NO

9. Has a government or regulatory agency (other than the police) determined that you inappropriately took or used the property of a client or patient? If Yes, state the name of the agency; the date; and the city, county and state where the incident occurred. Attach and initial additional sheet(s) if necessary. Name of Agency Month / Year City / County / State

YES

NO

10. Has a government or regulatory agency (other than the police) ever found that you abused an elderly person? If Yes, state the name of the agency; the date; and the city, county and state where the incident occurred. Attach and initial additional sheet(s) if necessary. Name of Agency Month / Year City / County / State

YES

NO

11. Have you ever had a license, certification, or approval to provide care, treatment, or educational services revoked, limited, or suspended? If Yes, state the name of the license, certification, or approval; indicate whether the license, certification, or approval was revoked, limited, or suspended; the date of the revocation, limitation, suspension; and the city, county and state where this occurred. Attach and initial additional sheet(s) if necessary. Name of License, Certification, or Approval Revoked / Limited / Suspended Month / Year City / County / State

YES

NO

12. Have you ever been denied licensure, certification, or approval? If Yes, state the name of the license certification or approval, the reason(s) for the denial and the city, county, and state where the denial occurred. Attach and initial additional sheet(s) if necessary. Name of License, Certification or Approval Reasons for Denial Month / Year City / County/ State

7

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

SECTION D ­ EMPLOYMENT HISTORY List all your employers for the last 5 years. Attach and initial additional sheet(s) if necessary.
Employer ­ Name, Address and Telephone Number Position Held / Job Title Dates Employed (From / To) Reason(s) for Leaving

SECTION E ­ FORMER ADDRESSES List all addresses you have used for the past 5 years. Include out of state addresses and addresses where you resided while serving in the U.S. Armed Forces. Attach and initial additional sheet(s) if necessary.
Street Address / P.O. Box, City, State and Zip Code Dates of Residence (From / To)

8

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

SECTION F ­ DOCUMENTS TO BE ATTACHED TO APPLICATION In addition to answering the questions in the previous sections, attach the following documents to this application. Failure to do so may result in a denial for submitting an incomplete application. 1. Your explanation of the crime(s) or offense(s) you committed (what you did and the reasons why). 2. Your explanation of the abuse, neglect, or misappropriation that you refer to on pages 6 and7 (what you did and the reasons why). 3. Your statement explaining the reasons you believe you are rehabilitated (what led to your committing the offense(s), your understanding of the impact of your offense on others, how you have changed since committing the offense(s).) 4. A copy of your discharge papers (DD-214), if you were discharged from a branch of the U.S. Armed Services within the past 3 years. 5. Background Information Disclosure Form. (HFS-64). 6. Background Information Disclosure Appendix (HFS-69), if you are a non-client resident, owner or representative of an entity, or representative of a governmental agency or tribe. 7. Caregiver Background Check results. The Caregiver Background Check is a computer printout of any criminal history that you may have and a letter titled "Response to Caregiver Background Check". 8. Criminal history check results from each state in which you have lived in the last 3 years. 9. Certified copies of Judgments of Conviction, Criminal Complaint, and Docket for each conviction listed on page 4. (Certified copies may be obtained from Clerk of Courts in the county where the conviction occurred. If unable to obtain, explain why.) 10. Letters from current and previous employers about your character and job performance. 11. Character references from at least 3 acquaintances. The reference must include his or her name, telephone number and address. 12. Proof or documentation of your compliance with court orders. 13. Letter from your probation/parole officer (if still on probation/parole or released within the past year). 14. Documentation of community service, volunteer work, training certificates restitution to victim or community, etc. 15. Any other information you want considered that demonstrates your rehabilitation. Please be advised that you may be required to submit additional information. SECTION G ­ DECISION DISTRIBUTION · · A copy of the decision will be sent to you at the address you gave on page 2. List the name and address of others to whom a copy of the decision should be sent (e.g., employer, school).

Name: Address: SECTION H ­ APPLICANT'S SIGNATURE AND NOTARY STATEMENT I certify that the information in this application is true and complete to the best of my knowledge.
SIGNATURE ­ Applicant Date Signed

Subscribed and sworn to before me this

day of

,

Notary Public, State of Wisconsin My Commission:

9

DEPARTMENT OF HEALTH SERVICES Office of Legal Counsel F-83263 (7/08)

STATE OF WISCONSIN

SECTION I ­ MAILING INSTRUCTIONS

Send your completed application and attachments to: · The Department of Health Services, if you are seeking employment; non-client residency; contracted services; or regulatory approval for or in a Department of Health Services regulated entity or if you are seeking to be approved by the Department as an adoptive parent or if you are currently employed; reside in; provide contracted services with; or have regulatory approval to operate a Department regulated entity; Department of Health Services Office of Legal Counsel One West Wilson Street, Room 651 P. O. Box 7850 Madison, WI 53707-7850 · Your county department of social or human services agency or licensed private child placing agency if you are seeking to become or are currently licensed as a foster home or treatment foster home or if you are seeking non-client residency in a foster home or a treatment foster home or if you are an adoptive parent and the county or licensed private child placing is providing adoption applicant home study services; Your local school board, if your are seeking a contract to provide day care services or are currently contracting to provide day care services with a school board under s. 120.14(13), Wis. Stats., or if you are seeking employment or non-client residency in an entity providing day care contracted services for a school board under s. 120.14(13), Wis. Stats., or if you are currently employed in or a non-client resident in an entity providing day care contracted services for a school board under s. 120.14(13), Wis. Stats. The DHS-designated tribe under which your entity operates.

·

·

10