Our agency screens prospective employees and volunteers to evaluate whether an applicant poses a risk of harm to the children and youth it serves. Information obtained is not an automatic bar to employment or volunteer work, but is considered in view of all relevant circumstances. This disclosure is required to be completed by former employers in order for the applicant to be considered.

APPLICANT:

______________________________________ Please print complete name and social security number.

As an agent of the former employer of the undersigned applicant, I affirm to the best of my knowledge that the undersigned applicant HAS NOT at ANY TIME:

Yes	No	(Initial answer under "yes" or "no" and provide brief explanation for a "yes" answer below.)
___	___	Been convicted of;
___	___	Pleaded guilty to (whether or not resulting in a conviction);
___	___	Pleaded nolo contendere or no contest to;
___	___	Admitted;
___	___	Had any judgment or order rendered against me (whether by default or otherwise);
___	___	Entered into any settlement of an action or claim of;
___	___	Had any license, certificate, or employment suspended, revoked, terminated, or adversely affected because of;
___	___	Been diagnosed as having or been treated for any mental or emotional condition arising from; or
___	___	Resigned under threat of termination of employment or volunteer work for;

Any allegation, any conduct, matter, or thing (irrespective of the formal name thereof) constituting or involving (whether under criminal or civil law of any jurisdiction):

Yes	No	(Initial answer under "yes" or "no" and provide brief explanation for a "yes" answer below.)
___	___	Any felony.
___	___	Rape or other sexual assault.
___	___	Drug- or alcohol-related offenses.
___	___	Abuse of a minor or child, whether physical or sexual.
___	___	Incest.
___	___	Kidnaping, false imprisonment, or abduction.
___	___	Sexual harassment.
___	___	Sexual exploitation of a minor.
___	___	Sexual conduct with a minor.
___	___	Annoying/molesting a child.
___	___	Lewdness and/or indecent exposure.
___	___	Lewd and lascivious behavior.
___	___	Obscene literature.
___	___	Assault, battery, or other offense involving a minor.
___	___	Endangerment of a child.
___	___	Any misdemeanor or other offense classification involving a minor or to which a minor was a witness.
___	___	Unfitness as a parent or custodian.
___	___	Removing children from a State or concealing children in violation of a law or court order.
___	___	Restrictions or limitations on contact or visitation with children or minors.
___	___	Similar or related conduct, matters, or things.
___	___	Accusation of any of the above.

Explanations:

(If you answered "yes" to any of the above, please explain. If none, write "none.")

Description	Dates
________________________________________________________________ ________________________________________________________________ ________________________________________________________________

The above statements are true and complete to the best of my knowledge.

__________ Date

___________________________________ Applicant's signature

Name:	____________________________
Title:	____________________________
Company:	____________________________
Address:	____________________________
City/State/ZIP:	____________________________
Phone:	____________________________

OJJDP Summary: Guidelines for the Screening of Persons Working with Children, the Elderly, and Individuals with Disabilities in Need of Support, April 1998