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DQA MIR WILMS Account Registration, F-02426 (11/2018)

The following information is required in order to register your Wisconsin Logon Management System (WILMS) account for use with the Division of Quality Assurance (DQA) Misconduct Incident Reporting (MIR) system. If you are unsure of your entity's license or certification number, you should consult the appropriate facility or provider directory on the DQA website at https://www.dhs.wisconsin.gov/guide/find.htm. Please direct any questions regarding this survey, or the MIR, to dhsdqamir@dhs.wisconsin.gov or 608-261-8319.
2. Provide the contact information of the person who is associated with the above WILMS logon ID/username. *This question is required.
Please fill in the required facility information below.

NOTE: Each facility can have up to two WILMS IDs associated with the facility; All other currently associated IDs will be deactivated (it is the responsibility of the facility to notify DQA when a WILMS ID should no longer be associated with a facility or if a previous user no longer has access to a WILMS ID.

Facility #1 *This question is required.


NOTE: Each facility can have up to two WILMS IDs associated with the facility; All other currently associated IDs will be deactivated (it is the responsibility of the facility to notify DQA when a WILMS ID should no longer be associated with a facility or if a previous user no longer has access to a WILMS ID.

Facility #2 *This question is required.


NOTE: Each facility can have up to two WILMS IDs associated with the facility; All other currently associated IDs will be deactivated (it is the responsibility of the facility to notify DQA when a WILMS ID should no longer be associated with a facility or if a previous user no longer has access to a WILMS ID.

Facility #3 *This question is required.


NOTE: Each facility can have up to two WILMS IDs associated with the facility; All other currently associated IDs will be deactivated (it is the responsibility of the facility to notify DQA when a WILMS ID should no longer be associated with a facility or if a previous user no longer has access to a WILMS ID.

Facility #4 *This question is required.


NOTE: Each facility can have up to two WILMS IDs associated with the facility; All other currently associated IDs will be deactivated (it is the responsibility of the facility to notify DQA when a WILMS ID should no longer be associated with a facility or if a previous user no longer has access to a WILMS ID.

Facility #5 *This question is required.
You will be contacted by DQA at the email address you provided above for additional information.