Background Questionnaire Concerning Sexual Abuse

All employees, applicants, volunteers, etc. will be required to execute an Authorization for Release of Information to conduct criminal background checks to the diocese, parish, school or institution.
 

1. Have you ever been convicted of a crime of sexual abuse, physical abuse, sexual harassment or exploitation?	Yes	No
2. Has any allegation or civil or criminal complaint ever been made against you relating to sexual abuse, sexual harassment or exploitation or physical abuse?	Yes	No
3. Have you ever terminated your employment or had your employment terminated for reasons relating to allegations of sexual abuse or physical abuse committed by you, or relating to civil or criminal complaints of sexual or physical abuse committed against you?	Yes	No
4. Have you ever received any medical treatment, physical or psychological, for reasons involving your physical or sexual abuse of others?	Yes	No

 
Date:_________________________ Signed: _________________________________


Print Name: __________________________________________________


Position: ____________________________________________________