Exposure Statement and Statement of Conduct

KOSTIC GROUP LLC

Exposure Statement and Statement of Conduct

Date

EXPOSURE TO HEPATITIS

Exposed to hepatitis

I have

have not

If you have been exposed, what is the date of exposure?

If I am exposed to hepatitis in the future, I understand that it is my obligation to report it to
the company immediately upon my knowledge.

EXPOSURE TO TUBERCULOSIS

Exposed to tuberculosis

I have

have not

If you have been exposed, what is the date of exposure?

When was your most recent TB test?

If I am exposed to tuberculosis in the future, I understand that it is my obligation to report
it to the company immediately upon my knowledge.

STATEMENT OF CONDUCT

I attest I have never done the following things: I have not abused, neglected, sexually
assaulted, exploited or deprived any person, nor is there any credible evidence that I have
subjected any person to serious injury as a result of my intentional or grossly negligent
misconduct.

Employee Signature

Accreditation

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