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Criminal Background Statement of Understanding and Release of Information

The Wisconsin Caregiver Law requires students to complete a Background Information Disclosure form (BID) and undergo a criminal background check prior to placement in a clinical or practicum site. Clinical/practicum sites have the right to refuse a student’s placement based on pending charges and conviction records. Mid-State will make two attempts to place a student at a clinical/practicum site, but pending charges and criminal convictions may impact a student’s ability to complete a program, get licensed, and/or obtain employment. Information about the Wisconsin Caregiver Law is contained on the Wisconsin Department of Health Services website.

A student with a criminal record is strongly encouraged to make an appointment with an Mid-State advisor. This allows the student to confidentially discuss any pending charges or convictions and the potential impact of those on future goals.

Criminal background checks for Mid-State are conducted by a private vendor. There is a fee for this service, which is the student’s responsibility. The fee is paid directly to the vendor by the student. You will find that this vendor provides you with features to help you organize and store information which will be accessible to you throughout your career.

Your signature indicates that you understand the Wisconsin Caregiver Law requirements and that you give permission for Mid-State Technical College to release conviction information to a clinical or practicum site.
By signing below, you acknowledge the following:
  • I am aware that my criminal background check will be released to a clinical or practicum site.
  • I am aware that my conviction record could affect successful course completion, graduation, and/or employment after graduation.

By typing my first and last name in this box, I confirm the data I have provided is accurate and that I understand the information provided on the form.



Note: You may receive the error message below after submitting this form. Here's why:
Error message : 1. Update - Lookup returned no record and aborted connector execution

Solution: We cannot find you in our records. Please check your entries for Student ID and the spelling of your first and last name. If you cannot resolve this issue, please call 888-575-6782 or, if you’re on campus, request help at the Student Services and Information Center.