Abuse Statement Form (Step 4 of 6)

have never shown, by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence), to have abused, neglected, sexually assaulted, exploited or deprived any person. I have never subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect.

**Any person found guilty of any of the above will not be hired by this agency.*