Questionnaire

Part I - Instructions

BEFORE answering these questions, please read the instructions below, including any instruction for the
location where you live or, if different, seek to provide services.

• Everywhere (U.S.): DO NOT identify: (a) any arrests, other than pending criminal charges, that did
not result in a conviction; (b) any juvenile offense; or (c) any record of any adult or juvenile arrest,
detention or conviction that has been sealed, expunged, annulled, erased, pardoned, shielded,
statutorily eradicated, set aside or otherwise dismissed by court order.

• California Providers: DO NOT identify: (1) Any misdemeanor conviction for which both (a)
probation has been successfully completed or otherwise discharged and (b) the case has been
dismissed by a court; (2) Any arrest, adjudication or conviction that occurred while you were subject
to the process and jurisdiction of a juvenile court; (3) Any arrest or detention that did not result in a
conviction; (4) Any record of a referral to, or participation in, any pretrial or post-trial diversion
program; (5) Any pending charges for which entry into a diversion program has taken place and final
disposition is pending; (6) Any offenses other than a felony or misdemeanor, such as an infraction; or
(7) Any of the following marijuana-related convictions entered by the court more than 2 years ago: an
infraction or a misdemeanor for unlawful possession of marijuana or a misdemeanor conviction for:
(a) transportation or giving away of up to 28.5 grams of marijuana, other than concentrated cannabis,
or the offering to transport or give away up to 28.5 grams of marijuana, other than concentrated
cannabis; (b) possession of paraphernalia used to smoke marijuana; (c) being in a place with
knowledge that marijuana was being used; or (d) being under the influence of marijuana.

• San Francisco, California, Providers: BEFORE answering the questions below, please also review
the San Francisco Fair Chance Ordinance Notice at [Link]
FCO%[Link]. DO NOT identify any information precluded by California state law
(including the information described above for all California Providers) or any information relating
to: (1) An arrest that did not lead to a conviction and is not the subject of an active pending criminal
investigation or trial; (2) Participation in or completion of a diversion or a deferral of judgment
program; (3) A conviction that has been judicially dismissed, expunged, voided, invalidated, or
otherwise rendered inoperative (for example, under California Penal Code sections 1203.4, 1203.4a,
or 1203.41); (4) A conviction or any other determination or adjudication in the juvenile justice
system, or a matter considered in or processed through the juvenile justice system; (5) A conviction
for which more than seven years has passed since the date of sentencing; (6) An offense other than a
felony or misdemeanor, such as an infraction; or (7) A conviction that arises out of conduct that has
been decriminalized since the date of sentencing (for example, the decriminalized conduct under
California Health and Safety Code Sections 11362.1 and 11362.2).

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• Colorado Providers: DO NOT identify information regarding a record of civil or military
disobedience, unless the record resulted in a plea of guilty or a conviction by a court of competent
jurisdiction. Also, DO NOT answer the question regarding charges currently pending and awaiting
disposition.

• Connecticut Providers: DO NOT identify any arrest, criminal charge or conviction the records of
which have been erased by a court based on sections 46b-146, 54-76o or 54-142a of the Connecticut
General Statutes. Criminal records subject to erasure under these sections are records concerning a
finding of delinquency or the fact that a child was a member of a family with service needs, an
adjudication as a youthful offender, a criminal charge that has been dismissed or not prosecuted, a
criminal charge for which the person was found not guilty, or a conviction for which the offender
received an absolute pardon. Any person whose criminal records have been judicially erased under
one or more of these sections is deemed to have never been arrested as it applies to the particular
proceedings that have been erased, and may so swear under oath.

• District of Columbia Providers: DO NOT identify any arrest or criminal accusation that is not
pending against you or did not result in a conviction.

• Georgia Providers: DO NOT identify any verdict or plea of guilty or nolo contendere that was
discharged by a court under Georgia’s First Offender Act.

• Hawaii Providers: DO NOT identify: (1) Any conviction older than 10 years, excluding any period
of time when you were incarcerated; or (2) Any crime which was subject to diversion or deferral.

• Massachusetts Providers: DO NOT identify: (1) Any record relating to prior arrests, criminal court
appearances or convictions for which the record has been sealed and is on file with the Commissioner
of Probation; (2) Any prior arrests, court appearances and adjudications in cases of delinquency or as
a child in need of services which did not result in a complaint transferred to the superior court for
criminal prosecution; (3) Any arrest, detention or disposition regarding any violation of law in which
no conviction resulted; (4) First-time misdemeanor convictions for drunkenness, simple assault,
speeding, minor traffic violations, affray or disturbance of the peace; (5) Convictions for other
misdemeanors where the date of conviction or the end of any period of incarceration was more than 3
years ago, unless there have been subsequent convictions within those 3 years; or (6) Any criminal
record, or anything related to a criminal record, that has been sealed or expunged pursuant to chapter
276 of the Massachusetts General Laws.

• Michigan Providers: DO NOT identify any misdemeanor arrests, detentions, or dispositions that did
not result in conviction, including any pending misdemeanor charges.

• Nebraska Providers: DO NOT identify a sealed juvenile record of arrest, custody, complaint,
disposition, diversion, adjudication or sentence.

• Nevada Providers: Please note that the discharge and dismissal of certain first time drug offenses,
after the accused has completed probation and any required treatment or educational programs, does
not constitute a “conviction” for purposes of employment, so DO NOT identify those offenses. You
may limit disclosure of misdemeanor convictions to those that occurred within the last seven years
and resulted in imprisonment.

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• New York Providers: You may answer “no record” concerning any criminal proceeding that
terminated in your favor, per section 160.50 of the New York Criminal Procedure Law; any criminal
proceeding that terminated in a “youthful offender adjudication,” as defined in section 720.35 of the
New York Criminal Procedure Law; any conviction for a “violation” that already has been sealed by
the court, per section 160.55 of the New York Criminal Procedure Law; and any conviction that was
sealed pursuant to section 160.58 of the New York Criminal Procedure Law, so DO NOT identify
those offenses.

• New York City, New York Providers: DO NOT identify any of the information indicated for “New
York Providers,” and also DO NOT identify arrests or criminal accusations that did not result in a
conviction (unless the arrest or criminal accusation is pending).

• Ohio Providers: DO NOT report any arrest or conviction for a misdemeanor drug violation as
defined under Ohio Rev. Code 2925.11.

• Portland, Oregon Providers: DO NOT identify: (1) Any arrest not leading to a conviction, except
where a crime is unresolved or charges are pending against you; (2) Any convictions that have been
judicially voided or expunged; or (3) Any charges that have been resolved through the completion of
a diversion or deferral of judgment program for offenses not involving physical harm or attempted
physical harm to a person.

• Pennsylvania Providers: DO NOT identify convictions for summary offenses or any expunged
convictions or criminal record information deemed limited access pursuant to 18 Pa. Cons. Stat. §§
9121, 9122.1, or 9122.2.

• Philadelphia, Pennsylvania Providers: DO NOT identify any of the information indicated for
“Pennsylvania Providers,” and also DO NOT identify information convictions that are older than 7
years, excluding any period of time when you were incarcerated.

• Washington Providers: DO NOT identify: (1) Any conviction entered by the court more than 10
years ago unless some period of incarceration resulting from that conviction took place within the last
10 years; or (2) Any vacated records.

• West Virginia Providers: You are not required to disclose the fact of any felony conviction if it was
a qualifying felony conviction that was subsequently reduced to a misdemeanor under applicable law.

• Madison, Wisconsin Providers: DO NOT identify any offense for which it has been over 3 years
since the last date that any of the following occurred: you were placed on probation, paroled, released
from incarceration, or paid a fine.

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 Part II - Questions

1. Have you ever been convicted of or pleaded guilty or no contest to any crime within the past 7 years?
(Answering “Yes” will not automatically bar you from providing services.)

� Yes � No

If you answered “Yes,” please provide the following additional information:

Nature of offense(s): Domestic violence

� Misdemeanor �Felony Year of conviction: 2022

___________________________________ State: TN
County: Maury ______________

2. Are charges for any criminal offenses pending against you in court? (Answering “Yes” will not
automatically bar you from providing services..)

� Yes � No

If you answered “Yes,” please provide the following additional information:

Nature of offense: ___________________________________________

� Misdemeanor �Felony

County: ___________________________________ State: ______________

Please use additional paper if you need more space to provide a complete answer.

***

I certify that all of the information furnished on this form is true, complete and accurate to the best of my
knowledge.

2024-05-12
______________________________________________________________________________
Signature Date

Shannon Cook
_______________________________________
Print Name