Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Lenawee County Health Department Standards of Conduct Certification Statement

  1. Standards of Conduct Employee Certification Statement

    I hereby certify that I have received a copy of, and read and understand, the Employee Standards of Conduct. I agree to abide and be bound by the provisions of these documents and will immediately report any real or potential violations to the Health Officer or the Compliance Officer. As used in this statement, “I” means both myself and the members of my immediate family.

  2. Please answer the following questions:

  3. 1. Have you violated any federal, state, or local laws? (other than traffic laws)*

  4. 2. Do you have an ownership or investment interest in, or serve as an employee, officer, director, trustee, manager, consultant, or member of, any supplier, vendor, competitor, or customer of the Lenawee County Health Department?*

  5. I understand and agree that I have a continuing obligation to report any information that conflicts with these certifications or that is relevant to the Standards that may develop or that I become aware of during the course of my employment. I agree to respond fully and completely to all questions put to me by the Lenawee County Health Department regarding these certifications and my compliance with the Standards, the Lenawee County Health Department governance regulations and my duties under law.

  6. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  7. Leave This Blank:

  8. This field is not part of the form submission.