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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: Employment/ Pre-Employment Reference and
Policy Number: 9.18
Effective Date: August 23, 2017
Chapter: Human Resources
UW Health believes that employing qualified individuals contributes to the overall strategic success of the
organization. Employment/pre-employment reference and background checks serve an important role in
promoting a safe and productive environment.
II. POLICY ELEMENTS
It is the policy of UW Health to apply consistent procedures for conducting and/or providing employment
verifications, background checks and other reference verifications, as appropriate, for all present and
former employees (including lateral transfers, promotions and new hires), volunteers, Graduate Medical
Education (GME) trainees, and students. Additionally, it is UW Health’s policy to ensure that it does not
employ any individual who is currently excluded, suspended, debarred or otherwise ineligible to
participate in federal health care programs or who has been convicted of a criminal offense related to the
provision of health care items or services and has not been reinstated in the federal health care programs
after a period of exclusion, suspension, debarment, or ineligibility (i.e., Ineligible Person). The guidelines
below are intended to fulfill these policies. Graduate Medical Education Administration (GME) is
responsible for completion of and compliance with the pre-employment reference and background checks
described below for the GME trainees.
III. PERSONS AFFECTED
This policy applies to all present and former regular and temporary employees, including GME trainees.
This policy does not apply to physicians who also have an appointment with University of Wisconsin
School of Medicine and Public Health as their primary employer is responsible for employment/
pre-employment reference and background checks.
For convenience, all those subject to this policy will be referred to as "employee," despite that, in some
cases, no employment relationship exists.
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A. A prospective external hire must provide an electronic release so UW Health can request and
conduct reference and background checks/investigations as allowed by the Fair Credit Reporting
Act, as part of the new hire process. UW Health will check work authorization, criminal
background, federal health care reimbursement sanctions and exclusions, and work experience.
UW Health may also verify education, licensure/certification, and other information, as
appropriate for the position. All offers are contingent upon successful completion of these checks,
although the employee may begin employment before the results of the caregiver background
check, education or degree verification, and work authorization are returned.
B. UW Health may choose to check criminal background and federal health care reimbursement
sanctions and exclusions at any point in an affected person's tenure with UW Health.
C. Employees have an ongoing obligation to inform their managers or an Employee Relations
Consultant (ERC) in the Human Resources (HR) department if they are arrested or convicted of a
crime, if their license or certification to practice expires, is suspended or revoked, or they are
excluded, suspended, debarred or otherwise ineligible to participate in federal health care
D. Reference Checks. (This section on reference checks does not apply to GME trainees).
Human Resources shall confirm previous employment and other relevant information required for
the job prior to an individual starting a position with UW Health. See Appendix A Manager’s
Guide to Pre-Employment References for more details. UW Health will offer a position pending
successful completion of the reference checks.
E. License/Certification Verification
Human Resources will conduct license or certification verification of new hires, based on
requirements for the position. Managers and/or supervisors are responsible for completing
verification of licensure/certification renewals following hire.
F. Caregiver Background Checks
Pursuant to the Wisconsin Caregiver Law and UW Health policy, UW Health shall conduct a
caregiver background check on all employees, or persons expected to be an employee, student,
volunteer, and any other persons in regular, direct contact with patients.
G. Medicare/Medicaid Sanction Checks
1. No UW Health facility, including hospitals, clinics and satellite offices may employ any
individual who is currently excluded, suspended, debarred or otherwise ineligible to
participate in federal health care programs or has been convicted of a criminal offense
related to the provision of health care items or services, and who has not been reinstated in
the federal health care programs after a period of exclusion, suspension, debarment, or
2. UW Health will terminate, following validation of correct identity, any current employee
who is listed as an Ineligible Person.
a. Additionally, pending the resolution of any criminal charges or proposals for
debarment or exclusion, UW Health will suspend individuals currently employed
pending the resolution of any criminal charges or proposals for debarment or
exclusion. If resolution results in conviction, debarment, or exclusion of the
individual, UW Health shall immediately terminate the employee's employment.
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b. UW Health shall conduct a check on each current employee, including GME trainees,
on a monthly basis. The results of the check shall be shared with the UW Health
Office of Compliance.
c. The List of Excluded Individuals and Entities (LEIE) Database of the Office of the
Inspector General and the System for Award Management (SAM) of the U.S.
General Services Administration (GSA) shall be checked for each employee.
d. Should an individual appearing in the database provide satisfactory evidence that
they are not the individual that appears on the list, the HR department will evaluate
the individual's continued involvement with UW Health.
H. Depending on the position and circumstances, UW Health may conduct additional background
checks including violent sexual offender and predator registries, certifications and designations
checks, professional disciplinary action registries, Department of Motor Vehicle driving records,
consumer credit reports, newspaper/media articles and clippings, and bankruptcy and court
I. Providing References
External References: Supervisors and managers may provide accurate, factual references in good
faith to outside entities, provided that an electronic or handwritten signature of release
accompanies the request. Factual information relating to interpersonal skills, attendance and
timeliness, teamwork skills, professionalism and technical expertise may be provided. If a written
release is not provided, supervisors and managers shall not respond to the request. If any
questions arise, supervisors or managers should consult with the HR Service Center.
The Vice President, Human Resources Operations must approve any exceptions to this policy.
A. Nursing Administrative Policy 4.12, RN/LPN License Verification
B. Hospital Administrative Policy 9.02, Verification of Work Authorization
C. Hospital Administrative Policy 9.03, Pre-Employment and Renewal Criminal Background
D. Hospital Administrative Policy 9.41, Verification of Licensure or Certification
This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made
for the purpose of inducing any person to become or remain an employee of UW Health, and should not
be considered "promises" or as granting "property" rights. UW Health may add to, subtract from and/or
modify this Policy at any time. Nothing contained in this Policy impairs the right of an employee or UW
Health to terminate the employment relationship at-will.
Sr. Management Sponsor: Vice President, Human Resources Operations
Authors: Director, Employee Relations; Director, Recruitment
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer