Free Request for Exemption - Intoxicated Driver Program (IDP) Employment of Individuals with Lesser Qualifications - Wisconsin


File Size: 14.4 kB
Pages: 1
Date: August 22, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: DHS
Word Count: 267 Words, 1,782 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/f2/f20691.pdf

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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