STAFF ABUSE MIS-CONDUCT STATEMENT FORM

I understand and acknowledge that I must comply with (Agency Name)

. Code of Conduct and Abuse or Misconduct program.

All laws, regulations, policies & procedure as well as any other applicable state or local ordinances as it pertains to the responsibilities of my position.

I understand that my failure to report any concerns regarding possible violations of these laws, regulations, and Policies may result in disciplinary action, up to and including termination.

I (Employee Name) as an employee of (Agency Name)

I hereby state that, I have never shown any misconduct nor have a history of abuse and neglect of others.

I acknowledge that I have received and read the Misconduct or abuse statement form and that I clearly understand it.

Name of Employee(print)

Employment Position

Who having been first duly sworn depose and say that (Employee name) has never sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury because of intentional or grossly negligent misconduct as evidence by an oral or written statement to this effect obtained at the time of application.

Print Name(Staff):