DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20691 (08/2008)
STATE OF WISCONSIN HFS 62.05(2)(a)
REQUEST FOR EXEMPTION INTOXICATED DRIVER PROGRAM (IDP)
EMPLOYMENT OF INDIVIDUALS WITH LESSER QUALIFICATIONS
Completion of this form is required under HFS 62.05(2)(a) when employing assessors who do not meet the minimum qualifications per subdivision 2 of HFS 62.05(2)(a) and must be submitted to DHS/Division of Mental Health and Substance Abuse Services/Bureau of Prevention Treatment and Recovery for approval. Failure to comply may result in forfeiture of the assessment facility's authority to conduct IDP assessments. Name of Assessment Facility Address Name - Contact Telephone Number - Contact
County
Name County IDP Designated Coordinator
Name Assessor for Whom Exemption is Being Requested Summary of Assessor's Credentials--Education and training, degrees and/or certifications, years of experience conducting IDP assessments
Per HFS 62.05(2)(a) 2., please describe the assessment facility's need as it pertains to employment of individuals with lesser qualifications than those required by Administrative Rule HFS 62.05(2)(a)1.
Does the above-named assessor have a plan to meet the requirements of a qualified assessor as defined in HFS No Yes--Please briefly describe plan, including timeline. 62.05(2)(a)1?
Please describe how the assessment agency will work toward employment of assessors who meet the requirements stated in the rule.
SIGNATURE Assessment Facility Contact SIGNATURE IDP Designated Coordinator
Date Signed Date Signed
FOR DEPARTMENT USE ONLY Name Reviewed By Comments Date Reviewed
Approved:
Yes
No
Approval Expires (Date):
Distribution: Original DHS
Copy - County AODA Coordinator