DQA Misconduct Reporting System (formerly 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 Reporting System (formerly MIR) . 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 MRS, to dhsdqamir@dhs.wisconsin.gov or 608-261-8319.

1. WILMS Logon ID/Username
Please note that if you do not already have an existing WILMS logon ID, you MUST create a WILMS logon ID prior to completing this survey. You may create a logon ID by accessing the WILMS web site at https://register.wisconsin.gov/AccountManagement/default.aspx

**Your WILMS logon ID will be your MIR username**
*This question is required.

2. Provide the contact information of the person who is associated with the above WILMS logon ID/username. *This question is required.

First Name

Last Name

Position/title *This question is required.

Phone Number

Email Address

4. Facility #1 License / Certification Number *This question is required.

Please fill in the required facility information below.

Facility #1 *This question is required.

Facility Name
Street Address
City

4. Facility #2 License / Certification Number *This question is required.

Facility #2 *This question is required.

Facility Name
Street Address
City

4. Facility #3 License / Certification Number *This question is required.

Facility #3 *This question is required.

Facility Name
Street Address
City

4. Facility #4 License / Certification Number *This question is required.

Facility #4 *This question is required.

Facility Name
Street Address
City

4. Facility #5 License / Certification Number *This question is required.

Facility #5 *This question is required.

Facility Name
Street Address
City

NOTE: If you selected 6 or more facilities please email the following information to dhsdqamir@dhs.wisconsin.gov

Facility Name
License #
Address
WILMS IDs (2 or less)