1. Have you ever exhibited any behavior or conduct which might negatively impact your ability to serve in a role which requires a certificate, credential, or license? *
1. Have you ever exhibited any behavior or conduct which might negatively impact your ability to serve in a role which requires a certificate, credential, or license? - Yes
1. Have you ever exhibited any behavior or conduct which might negatively impact your ability to serve in a role which requires a certificate, credential, or license? - No
2. In the past 10 years, have you ever engaged in any conduct which resulted in the damage or destruction of property? (For purposes of questions 2 and 3, property includes both real and personal property owned by you or another. Do not list damages done as the result of an automobile accident.) *
2. In the past 10 years, have you ever engaged in any conduct which resulted in the damage or destruction of property? (For purposes of questions 2 and 3, property includes both real and personal property owned by you or another. Do not list damages done as the result of an automobile accident.) - Yes
2. In the past 10 years, have you ever engaged in any conduct which resulted in the damage or destruction of property? (For purposes of questions 2 and 3, property includes both real and personal property owned by you or another. Do not list damages done as the result of an automobile accident.) - No
3. In the last 10 years, have you ever threatened to damage or destroy property? *
3. In the last 10 years, have you ever threatened to damage or destroy property? - Yes
3. In the last 10 years, have you ever threatened to damage or destroy property? - No
4. Have you ever engaged in any conduct which resulted in the physical injury or harm of any person(s)? (Do not list 4. injury or harm caused as the result of duties performed due to a job assignment such as police officer, armed forces member, or athlete.) *
4. Have you ever engaged in any conduct which resulted in the physical injury or harm of any person(s)? (Do not list 4. injury or harm caused as the result of duties performed due to a job assignment such as police officer, armed forces member, or athlete.) - Yes
4. Have you ever engaged in any conduct which resulted in the physical injury or harm of any person(s)? (Do not list 4. injury or harm caused as the result of duties performed due to a job assignment such as police officer, armed forces member, or athlete.) - No
5. Have you ever threatened to do physical injury or harm to any person(s)? (Do not list threats issued as the result of 5. duties performed due to a job assignment such as police officer, armed forces member, or athlete.) *
5. Have you ever threatened to do physical injury or harm to any person(s)? (Do not list threats issued as the result of 5. duties performed due to a job assignment such as police officer, armed forces member, or athlete.) - Yes
5. Have you ever threatened to do physical injury or harm to any person(s)? (Do not list threats issued as the result of 5. duties performed due to a job assignment such as police officer, armed forces member, or athlete.) - No
6. Do you have a medical condition which in any way impairs or limits your ability to serve in a certificated role with reasonable skill and safety? *
6. Do you have a medical condition which in any way impairs or limits your ability to serve in a certificated role with reasonable skill and safety? - Yes
6. Do you have a medical condition which in any way impairs or limits your ability to serve in a certificated role with reasonable skill and safety? - No
7. If you use chemical substance(s), does this use in any way impair or limit your ability to serve in a certificated role with reasonable skill and safety? *
7. If you use chemical substance(s), does this use in any way impair or limit your ability to serve in a certificated role with reasonable skill and safety? - Yes
7. If you use chemical substance(s), does this use in any way impair or limit your ability to serve in a certificated role with reasonable skill and safety? - No
8. If you disclosed a “yes” answer to questions 6 or 7 above, are the limitations or impairments caused by your medical condition(s) or substance abuse reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring program? Please explain on a separate sheet of paper and provide the name, address, and telephone number of the program. *
8. If you disclosed a “yes” answer to questions 6 or 7 above, are the limitations or impairments caused by your medical condition(s) or substance abuse reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring program? Please explain on a separate sheet of paper and provide the name, address, and telephone number of the program. - Yes
8. If you disclosed a “yes” answer to questions 6 or 7 above, are the limitations or impairments caused by your medical condition(s) or substance abuse reduced or ameliorated because you receive ongoing treatment (with or without medications) or participate in a monitoring program? Please explain on a separate sheet of paper and provide the name, address, and telephone number of the program. - No
9. Do you currently use illegal drugs? *
9. Do you currently use illegal drugs? - Yes
9. Do you currently use illegal drugs? - No
10. Have you used illegal drugs in the last year? *
10. Have you used illegal drugs in the last year? - Yes
10. Have you used illegal drugs in the last year? - No
11. If you disclosed a “yes” answer to question 9 above, have you successfully completed or are you participating in a supervised rehabilitation program? Please explain on a separate sheet of paper and provide the name, address, and telephone number of the program. *
11. If you disclosed a “yes” answer to question 9 above, have you successfully completed or are you participating in a supervised rehabilitation program? Please explain on a separate sheet of paper and provide the name, address, and telephone number of the program. - Yes
11. If you disclosed a “yes” answer to question 9 above, have you successfully completed or are you participating in a supervised rehabilitation program? Please explain on a separate sheet of paper and provide the name, address, and telephone number of the program. - No