Gees Home Caring Agency, LLC
Abuse, Neglect Attestation
Name
First Name
Last Name
I attest that there is no existing evidence or facts that I have abused, neglected, sexually assaulted, exploited, or deprived any person(s). I attest that there is no existing evidence that I have subjected any persons to serious injury as a result of intentional negligence, misconduct, or other actions. I understand that this information is a Georgia State Department of Human Resources Regulation within the Office of Regulatory Services Chapter 290-5-54.
Employee Signature
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Agency Signature
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Submit
Should be Empty: