Employment - Serenity Care Agency

Application For Employment

Serenity Care Agency LLC 715-308-3800

We are an Equal Opportunity Employer and committed to excellence through diversity

Please print or type. The application must be fully completed to be considered. Please complete each section, even if you attach a resume.

PERSONAL INFORMATION

Name*

First Last

Address*

City*

State*

Zip*

Phone*

Email*

Are you legally eligible to work in the US?*

Yes
No

Are you a veteran?*

Yes
No

If selected for employment are you willing to submit to a background check?*

Yes
No

POSITION

Position you are applying for*

Available start date*

Desired pay*

Employment desired*

Full time
Part time
Seasonal/Temporary

EDUCATION

School name (1)*	Location*	Years attended*	Degree received*	Major
School name (2)	Location	Years attended	Degree received	Major
School name (3)	Location	Years attended	Degree received	Major
School name (4)	Location	Years attended	Degree received	Major

REFERENCES (business and professional only)

Name (1)

Title

Company

Phone

Name (2)

Title

Company

Phone

Name (3)

Title

Company

Phone

Name (4)

Title

Company

Phone

EMPLOYMENT HISTORY

Employer (1)

Job Title

Dates employed

Work Phone

Starting pay rate

Ending pay rate

Address

City

State

Zip

Employer (2)

Job Title

Dates employed

Work Phone

Starting pay rate

Ending pay rate

Address

City

State

Zip

Employer (3)

Job Title

Dates employed

Work Phone

Starting pay rate

Ending pay rate

Address

City

State

Zip

SIGNATURE DISCLAIMER

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my employment being terminated.

Name*

Signature*

Date*

BACKGROUND INFORMATION DISCLOSURE INSTRUCTIONS

The Background Information Disclosure form (HFS64) gathers information as required by the Wisconsin Caregiver Background Check Law to help employers and governmental regulatory agencies make employment, contract, residency, and regulatory decisions. Complete and return the entire form and attach explanations as specified by employer or governmental regulatory agency.

CAREGIVER BACKGROUND CHECK LAW

In accordance with the provisions of sections 48.685 and 50.065 of the Wisconsin Statutes, for persons who have been convicted of certain acts, crimes or offenses:
1. The Department of Health and Family Services (DHFS) may not license, certify or register the person or entity (Note: Employers and Care Providers are referred to as “entities”);
2. A county agency may not certify a day care or license a foster or treatment foster home;
3. A child placing agency may not license a foster or treatment foster home or contract with an adoptive parent applicant for a child adoption;
4. A school board may not contract with a licensed day care provider; and
5. An entity may not employ, contract with or permit persons to reside at the entity.
A list of barred crimes and offenses requiring rehabilitation review is available from the regulatory agencies or through the Internet at http://www.dhfs.state.wi.us/ at the Licensing link and then under the Caregiver Program link.

THE CAREGIVER LAW COVERS THE FOLLOWING EMPLOYERS / CARE PROVIDERS (REFERRED TO AS “ENTITIES”)

Programs Regulated Under Chapter 48 of Wisconsin Statute	Treatment Foster Care, Family Day Care Centers, Group Day Care Centers, Residential Care Centers for Children and Youth, Child Placing Agencies, Day Camps for Children, Family Foster Homes for Children, Group Homes for Children, Shelter Care Facilities for Children, and Certified Family Day Care.
Programs Regulated Under Chapters 50, 51, and 146 of Wisconsin Statute.	Emergency Mental Health Service Programs, Mental Health Day Treatment Services for Children, Community Mental Health, Developmental Disabilities, AODA Services, Community Support Programs, Community Based Residential Facilities, 3-4 Bed Adult Family Homes, Residential Care Apartment Complexes, Ambulance Service Providers, Hospitals, Rural Medical Centers, Hospices, Nursing Homes, Facilities for the Developmentally Disabled, and Home Health Agencies – including those that provide personal care services.
Others	Day Care Providers contracted through Local School Boards

THE CAREGIVER LAW COVERS THE FOLLOWING PERSONS

• Anyone employed by or contracting with a covered entity who has access to the clients served, except if the access is infrequent or sporadic and service is not directly related to care of the client.
• Anyone who is a Day Care Provider who contracts with a School Board under Wisconsin Statute 120.13 (14).
• Anyone who lives on the premises of a covered entity and is 10 years old or over, but is not a client (“nonclient resident”).
• Anyone who is licensed by DHFS.
• Anyone who has a foster home licensed by DHFS.
• Anyone certified by DHFS.
• Anyone who is a Day Care Provider certified by a county department.
• Anyone registered by DHFS.
• Anyone who is a board member or corporate officer who has access to the clients served.

FAIR EMPLOYMENT ACT

Wisconsin’s Fair Employment Law, ss. 111.31 - 111.395, Wisconsin Statutes, prohibits discrimination because of a criminal record or pending charge; however, it is not discrimination to decline to hire or license a person based on the person’s arrest or conviction record if the arrest or conviction is substantially related to the circumstances of the particular job or licensed activity.

PERSONALLY IDENTIFIABLE INFORMATION:

This information is used to obtain relevant data as required by the provisions set forth by the Wisconsin Caregiver Background Check Law. Providing your social security number is voluntary, however your social security number is one of the unique identifiers used to prevent incorrect matches. For example, the Department of Justice uses social security numbers, names, gender, race, and date of birth to prevent incorrect matches of persons with criminal convictions. The Department of Health and Family Services’ Caregiver Registry uses social security numbers as one identifier to prevent incorrect matches of persons with findings of abuse or neglect of a client or misappropriation of a client’s property.

BACKGROUND INFORMATION DISCLOSURE

Completion of this form is required under the provisions of sections 48.685 and 50.065 of the Wisconsin Statutes. Failure to comply may result in a denial or revocation of your license, certification or registration; or denial or termination of your employment or contract. Refer to the attached instructions (HFS-64 A) for additional information. Providing your social security number is voluntary, however, your social security number is one of the unique identifiers used to prevent incorrect matches.
Please print your answers.

Check the box that applies to you.*

Employe / Contractor (lncluding new applicant)
Household member / lives on premises - but not a client
Applicant for a license or certification or registration (including continuation or renewal)
Other – specify:

NOTE: If you are an owner, operator, board member, or nonclient resident of a Bureau of Quality Assurance (BQA) regulated facility (1) print only your first, middle and last name; (2) complete Sections A and B; (3) sign the form; (4) complete the Appendix, HFS-69, in its entirety and (5) submit this form and the Appendix to the address noted in the Appendix Instructions.

Name

First Middle Last

Position Title

(Complete only if you are a prospective employee or contractor, or a current employee or contractor.)

Any other names by which you have been known

(including maiden name)

Birthdate

Gender

Male
Female

Race

Address

Social Security Number(s)

Section A - ACTS, CRIMES AND OFFENSES THAT MAY ACT AS A BAR OR RESTRICTION

1. Do you have criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, local, military and tribal courts?*

Yes
No

➢ If Yes, list each crime, when it occurred or the date of the conviction, and the city and state where the court is located. You may be asked to supply additional information including a certified copy of the judgement of conviction, a copy of the criminal complaint, or any other relevant court or police documents.

2. Were you ever found to be (adjudicated) delinquent by a court of law on or after your 10th birthday for a crime or offense? (NOTE: A response to this question is only required for group and family day care centers for children and day camps for children.)

Yes
No

➢ If Yes, list each crime, when and where it happened, and the location of the court (city and state). You may be asked to supply additional information including a certified copy of the delinquency petition, the delinquency adjudication, or any other relevant court or police documents.

3. Has any government or regulatory agency (other than the police) ever found that you committed child abuse or neglect? A response is required if the box below is checked:

Yes
No

(Only employers and regulatory agencies entitled to obtain this information per sec. 48.981(7) are authorized to, and should, check this box.)

➢ If Yes, explain, including when and where it happened

4. Has any government or regulatory agency (other than the police) ever found that you abused or neglected any person or client?

Yes
No

➢ If Yes, explain, including when and where it happened.

5. Has any government or regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client?

Yes
No

➢ If Yes, explain, including when and where it happened.

6. Has any government or regulatory agency (other than the police) ever found that you abused an elderly person?

Yes
No

➢ If Yes, explain, including when and where it happened.

7. Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?

Yes
No

➢ If Yes, explain, including credential name, limitations or restrictions, and time period.

Section B – OTHER REQUIRED INFORMATION

1. Has any government or regulatory agency ever limited, denied or revoked your license, certification or registration to provide care, treatment or educational services?

Yes
No

➢ If Yes, explain, including when and where it happened.

2. Has any government or regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility?

Yes
No

➢ If Yes, explain, including when and where it happened and the reason.

3. Have you been discharged from a branch of the US Armed Forces, including any reserve component?

Yes
No

➢ If Yes, attach a copy of your discharge papers (DD214) if you were discharged within the past 3 years.

Max. file size: 100 MB.

➢ You may be asked to provide a copy of your DD214 if your discharge occurred more than 3 years ago.

4. Have you resided outside of Wisconsin in the last 3 years?

Yes
No

➢ If Yes, list each state and the dates you lived there

5. Have you had a caregiver background check done within the last 4 years?

Yes
No

➢ If Yes, list the date of each check, and the name, address and phone number of the person, facility or government agency that conducted each check.

6. Have you ever requested a rehabilitation review with the Wisconsin Department of Health and Family Services, a county department, a private child placing agency, school board, or DHFS designated tribe?

Yes
No

➢ If Yes, list the review date and the review result. You may be asked to provide a copy of the review decision.

A “NO” answer to all questions does not guarantee employment, residency, a contract or regulatory approval.

I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in HFS 12.05 (4), Wis. Adm. Code.

Your Signature*

Date Signed*