EMPLOYMENT HISTORY REVIEW FORM
CHILD SEXUAL ABUSE AND SEXUAL MISCONDUCT
Pursuant to Section 6-113.2 of the Education Article, Annotated Code of Maryland
TO:
Name of Current or Former Employer:
Contact Person:
Title:
Street Address:
City:
State:
Zip Code:
Telephone Number:
Fax Number:
E-Mail Address:
The Applicant named below is under consideration for a position with our entity. The State of Maryland requires that information
must be obtained from current/former employers to ensure the safety of our students. The Applicant has reported previous
employment with your entity. Please provide the information requested on this form within 20 calendar days as required by law
to the prospective employer indicated at the bottom of the second page of this form. If you answer yes to any of these questions,
you will need to provide additional information as requested by our entity.
Applicant’s Name (First, Middle, Last): _____________________________________________________________________________
Any former names:
TO BE COMPLETED BY CURRENT OR FORMER EMPLOYER:
Dates of Employment of Applicant: ____________________________ to ___________________________
Positions Held by Applicant: _____________________________________________________________________________________
To the best of your knowledge, has the Applicant named on this form ever:
the investigation resulted in a finding by the school system, the board of education, or an arbitrator that the
YES NO
(unless the investigation resulted in a finding that the allegations lacked sufficient evidence according to the
YES NO
the investigation resulted in a finding that the allegations lacked sufficient evidence according to state law or the
YES NO
YES NO
(unless the investigation resulted in a finding that the allegations were ruled out or the allegations were screened
YES NO
separated from any employment while allegations of child sexual abuse or sexual misconduct were pending or
YES NO
sexual abuse or sexual misconduct were pending or under investigation, or due to an adjudication or findings of
YES NO
I decline to answer because: it is against the laws of my state; I am restricted by a contract entered into before June 30, 2019.
Name of Employer Representative
Title
Signature of Employer Representative
Date
Phone Number
E-Mail Address
Under Maryland law, a person acting in good faith may not be held liable for disclosing any information or records related to child sexual abuse or sexual misconduct about a
current or former employee’s professional conduct or reason for termination of employment in accordance with the law unless the person acted with actual malice toward the
employee or former employee or intentionally or recklessly disclosed false information about the employee or former employee. This immunity from liability shall be in addition
to and not a limitation of any other immunity provided by law or any absolute or conditional privilege applicable to the disclosure of information or records or the Applicant’s
consent to the disclosure. Willful failure to respond to or provide the information requested on this form may result in civil penalties or professional discipline.
Rev 3.11.2020
Applicant certification to be completed by the Applicant for the current employer, each former school employer, and each former
employer where the Applicant was employed in a position involving direct contact with minors, as defined by Maryland law:
Applicant’s Name (First, Middle, Last):
If no current or former applicable employment, check here
Any former names by which the Applicant has been identified:
Date of Birth: Last 4 Digits of Applicant’s Social Security Number:
Approximate dates of employment with the entity listed above:
Position(s) held with the entity:
TO BE COMPLETED BY THE APPLICANT:
Have you ever:
the investigation resulted in a finding by the school system, the board of education, or an arbitrator that the
YES NO
(unless the investigation resulted in a finding that the allegations lacked sufficient evidence according to the
YES NO
the investigation resulted in a finding that the allegations lacked sufficient evidence according to state law or the
YES NO
YES NO
(unless the investigation resulted in a finding that the allegations were ruled out or the allegations were screened
YES NO
separated from any employment while allegations of child sexual abuse or sexual misconduct were pending or
YES NO
sexual abuse or sexual misconduct were pending or under investigation, or due to an adjudication or findings of
YES NO
By signing this form, I understand that if I provide false information or willfully fail to disclose material information required by this
form I will be subject to professional discipline up to and including termination and denial of employment, and any other criminal or
civil penalties in accordance with state law and regulations. I hereby authorize the employer named on this form to release the
requested information, and any other information permitted by law, to the entity listed below. I release, waive and discharge the
employer identified on this form and the entity named below from any and all liability of any kind that may arise from the disclosure
and use of the information provided on this form.
_________________________________________________________ _______________________________________
Signature of Applicant Date
Please return this form to:
School Entity/Contracting Agency: Contact Person: Title:
Street Address: City, State, Zip Code:
Phone Number: Fax Number: E-Mail Address:
[EMPLOYER USE ONLY] -- Date Form Received: ______________ Received by: ____________________________
Rev 3.11.2020
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