Fillable List Of Indiv Working With Minors

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List Of Indiv Working With Minors

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Reporting Form Part 2
Individuals for WI Caregiver Act
Working with Minors
Name Current Resident Employee Volunteer Student Other Comments
Address Status
City, State, Zip
Yes No
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Name of Person submitting this form and contact number:
Department/Unit: Event/Program:
* Note:
Date submitted:
Submit to Office of Risk Management BC = Wis. Caregiver Background Check
*4/09
Wisconsin Caregiver
BC* for UPP 4-26
in past 4 yrs
Working with Minors
Please mark appropriate status box
Instructions
Note: This form should accompany
the Report Form for Events
involving minors Part 1 in
compliance with UPP 4-26.
This form may also be used to
update and communicate additional
persons who may be identified for
inclusion as part of the event after
the initial list has been submitted.
This form should be used to identify
persons involved in the event(s)
when the event is recurring after
the initial submission and at least
annually for ongoing programs.
Other Status Box: Please use this
space to identify individuals who
maybe employed as advisors or
coaches paid by student
organizations or others or adjunct
faculty that may not have a current
teaching assignment.
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List Of Indiv Working With Minors

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Completed 28 February 2020

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