Exposure Statement and Statement of Conduct

KOSTIC GROUP LLC

Exposure Statement and Statement of Conduct

First name *

Last name *

Date *

Exposure To Hepatitis

Have you been exposed to Hepatitis? *

Yes

No

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

Have you been exposed to Tuberculosis? *

Yes

No

Date of Exposure *

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 *

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KOSTIC GROUP LLC