Name of Agency & Region: IIIIII JOURNEYS IN COMMUNITY LIVING

IIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII MIDDLE TENNESSEE REGION

I certify and affirm that, to the best of my knowledge and belief; I

had a case of abuse, neglect, mistreatment, or exploitation against me. In order to verify this affirmation, I release and authorize JOURNEYS IN COMMUNITY LIVING and the TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (DIDD) to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business, entitty or agency, whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment, or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personnel or investigative reports concerning my employment with this employer to my future employers who may be providers of services under contract with DIDD.

Witness: ____________________________ Date: ____________________

(For Journeys' Use Only)

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