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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Caregiver Background Checks
Policy Number: 9.03
Effective Date: March 1, 2017
Chapter: Human Resources
UW Health believes in promoting a safe environment for all persons, including patients, families, visitors
and employees. UW Health shall review caregiver background records of all employees, persons expected
to be employees, contractors, volunteers, students, and temporary agency personnel, consistent with state
and federal laws.
II. POLICY ELEMENTS
All employees, persons expected to be employees, volunteers, and other persons in regular, direct contact
with patients must submit a Background Information Disclosure (BID) form prior to starting to work or
training. A check must be completed within sixty (60) days of the start of employment or training. UW
Health shall make a good faith effort to complete out-of-state background checks within the sixty (60) day
timeframe. A completed check is not required for persons whose direct patient contact at UW Health ends
less than 60 days after it begins.
UW Health will conduct a renewal background check at least every four (4) years or at any time when
there is reason to believe a renewal check should be obtained.
All individuals covered by this policy have a continuing obligation to report any new arrests and/or
convictions as they occur to their supervisor/manager or directly to Human Resources (HR). Any
manager who receives such information shall immediately report it to HR. A person may be subject to
disciplinary action and/or sanctions if they provide false information on a BID form or fail to report new
arrests, convictions, findings, or license limitations in a timely manner (estimated as within two weeks of
the arrest, conviction, finding or license limitation). Administrative Policy 9.04-Work Rules: UWHC
III. PERSONS AFFECTED
This policy applies to all existing and potential regular Authority employees, volunteers,
and students, agency or contracted personnel, and any other persons in regular, direct contact with
patients. As a general practice, UW Health will conduct checks on all employees.
The Vendor Liaison Office shall administer this policy for those vendors who have regular, direct patient
contact. This policy does not apply to members of the medical staff. Caregiver background checks on
medical staff that have privileges are conducted by the Medical Staff Affairs Office.
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Regular, Direct Contact: Regular means contact that is planned, scheduled, expected or periodic. “Direct
contact", when used in reference to a person's contact with patients, means face-to-face physical
proximity to a patient that affords the opportunity to commit abuse or neglect of a patient or
misappropriation of a patient's property.
A. All volunteers and new hires must complete a BID form and submit any relevant court documents
for disclosed convictions. For new hires, the BID form and supporting documents will be
collected post-offer but prior to start date. New hires and volunteers shall not begin work until a
completed BID form has been submitted. The Recruitment department shall receive these forms
for new hires, and the Volunteer Services department shall receive these forms for volunteers.
B. Persons who misrepresent, falsify or knowingly omit information on the BID may be terminated
or have the offer of employment withdrawn.
C. If a new hire or volunteer has disclosed criminal conviction(s) on the BID form, the Recruitment
representative or Volunteer Services shall request the criminal complaint, judgment of conviction
and any other relevant documents. It is the responsibility of the new hire or volunteer to secure
and provide these. If no documents are received or are not received in a timely manner, the offer
of employment may be rescinded. HR may waive this requirement or accept alternate
documentation when appropriate.
D. All new employees and volunteers who served in the Armed Forces, regular or reserves, must
provide discharge papers (DD214) if they were discharged within the past three (3)
years. Additional information may also be requested if the discharge is other than "honorable."
E. The Recruitment representative, and HR Compliance if appropriate, shall review the BID form
and supporting documents to determine if the information precludes employment. The Volunteer
Services Office shall conduct this review for volunteers, in consultation with HR Compliance if
F. Once this review is completed and employment is not precluded, the person may start work or as
G. If the new employee or volunteer has a conviction or a pending arrest for crimes that act as
statutory bar to employment, the employee shall be barred from employment/volunteering at UW
Health. See Wis. Admin. Code Chapter DHS 12, Appendix A.
H. Final applicants and volunteers may be denied if there is a substantial relationship between their
criminal history and the position for which they are being hired. This determination shall be made
consistent with state law.
I. The final decision to rescind an offer of employment shall be made by HR Compliance/Corporate
J. A complete Wisconsin Caregiver Background Check includes:
1. A criminal history search through Wisconsin Department of Justice (DOJ);
2. A check of the status of professional licenses and credentials through the Wisconsin
Department of Regulation and Licensing (DRL); and
3. A review of records kept by Wisconsin Department of Health and Family Services
(DHFS) for any substantiated findings of abuse or neglect and license restrictions or
K. A renewal check shall be completed at least every four (4) years or more often as appropriate. An
employee or volunteer who fails to return a BID form in a timely manner will be removed from
employment or volunteering. If a renewal check reveals a new criminal history, it will be
addressed in accordance with the guidelines above. If this periodic check determines that a prior
criminal history was overlooked, UW Health reserves the right to reevaluate previous
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decisions. Additionally, if a renewal check reveals that an employee or volunteer failed to report a
new arrest or conviction, appropriate disciplinary action, including termination, may result.
L. Graduate Medical Education will collect the required documents from the Graduate Medical
Education trainees and provide that information to Human Resources for processing of the
background check. Any employment actions taken as a result of a background check will be
handled by Graduate Medical Education.
M. All temporary agency personnel, travelers, students, contractors or other persons having regular,
direct contact with patients must submit a BID form prior to starting to work or train, and at least
every four (4) years thereafter from their start date. In general, these individuals will be required
to submit the BID form to their school, agency or employer. These individuals shall not begin
work or training until the completed background check or letter confirming same has been
reviewed and accepted by Human Resources.
1. The individual, school, temporary employment agency or other entity is responsible for
conducting the Wisconsin Caregiver Background check, out-of-state checks, and
associated costs. They will inform UW Health that the person(s) has no offenses and is
therefore eligible for clinical placement or work at UW Health. The school or agency
must also advise UW Health of any convictions so that UW Health may consider whether
any are substantially related to the duties, and the actual caregiver background check
results may be forwarded to UW Health for review.
2. If the check reveals a criminal history, the final decision to permit someone to work or
train shall be made by HR Compliance.
VI. RECORD RETENTION AND STORAGE
The Caregiver Background Check forms and related documents will be maintained by the HR department
separate from the personnel files. All forms will be retained for a minimum of four (4) years after an
employee's employment at UW Health ends.
Administrative Policy 9.04-Work Rules: UWHC Authority
Wisconsin Caregiver Law
Wisconsin Fair Employment Act
Sr. Management Sponsor: VP, Human Resources Operations
Author: HR Compliance/Corporate Counsel
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer
Previous revision: 102013
Next revision: 032020