Primary Sexual Misconduct Questionnaire (SMQ) 2023-2024

Name

This address will receive a confirmation email

Phone

Address

Part I

1. Have you filled out this questionnaire for this church or agency within the past 2 years?

Yes. I have completed this form in the last 2 years. No. If no, please answer questions 2 through 9 in PART II.

If YES, Go to Annual Renewal Sexual Misconduct Questionnaire (SMQ).

Part II

2. Have you ever been accused, in a written and signed statement, of sexual misconduct with a child or youth?

Yes No

3. Have you ever been accused in a written and signed statement, of sexual misconduct with an adult?

Yes No

4. Have you ever been dismissed from any position, volunteer or salaried, because of accusations of sexual misconduct on your part?

Yes No

5. Have you ever resigned from any position, volunteer or salaried, because of an accusation of sexual misconduct on your part, or to avoid being dismissed because of an accusation of sexual misconduct on your part?

Yes No

6. If your response to any of the foregoing questions (2 through 5) is “yes”, please provide in the box below, all details regarding each accusation of sexual misconduct that has been made with respect to you, including a description of the alleged conduct, the name of the person who made the accusation, the date of the alleged misconduct, and the name of your employer at the time of the alleged misconduct.

7a. Have accusations of sexual misconduct on your part ever resulted in civil or criminal court proceedings at any level (e.g., indictment, arrest, trial, etc.)?

Yes No

If yes, please provide details of proceedings mentioned in question 7a. Please provide the complete details of those proceedings (including dates, circumstances, the jurisdiction where the proceedings occurred, the nature of the accusations, and the result of the proceedings) here.

7b. Have accusations of sexual misconduct against you resulted in civil or criminal court proceedings on more than one occasion?

Yes No

If yes, please provide the same details with respect to each such proceeding.

8. Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people?

Yes No

Provide explanation below.

Personal References

9. Please provide three adult references (names, full addresses, and phone numbers) of persons who are not related to you by blood, marriage or other family relationship and are not employed or supervised by you, who can, to the best of their ability, provide statements in support of your good character and clean record in regard to sexual misconduct with children, youth, and adults.

Name of Reference 1

Address

Phone

Name of Reference 2

Address

Phone

Name of Reference 3

Address

Phone

Signature Verification

To be signed by all laypersons and un-appointed clergy who work with children or youth within the local church or a conference agency.

I verify that the answers I have provided on this Questionnaire are true and accurate to the best of my ability. I will comply with the HUMC Safe Sanctuaries Policy. I understand that false answers, as well as the failure to sign this Response Form, will result in my being denied the position for which I am being considered.

By entering my name in the box below I am providing my digital signature on this form.

Electronic Signature

Date of Signature

Primary Sexual Misconduct Questionnaire (SMQ) 2023-2024

Description

Please Fix the Following