Fillable Employee Self-Reporting of Arrests, Criminal Charges, CPS Investigations (Prince George's County Public Schools)

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Employee Self-Reporting of Arrests, Criminal Charges, CPS Investigations (Prince George's County Public Schools)

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Employee Self-Reporting of Arrests, Criminal Charges,
CPS Investigations and Findings & Incarceration
Attachment to AP 4215
INSTRUCTIONS: Any person employed by PGCPS in any capacity (including, but not limited to full- or
part-time, probationary or non-probationary, employed in a temporary or seasonal capacity, or
substitute teachers) shall report an arrest, criminal charges, CPS Investigation and finding, or
incarceration for any of the offenses listed on this form as well as the disposition of any ensuing criminal
proceeding.
The employee may report the information on this form to the Employee and Labor Relations Office
(ELRO) within seven (7) business days (i.e., days that PGCPS offices are open) of the arrest, charge,
indication, etc. Self-reporting must occur regardless of where the alleged criminal activity occurred and
whether or not it was within the scope of the employee’s job duties. Self-reporting the required
information will not be considered or treated as an admission of guilt. Forms should be submitted to
elro.investigation@pgcps.org.
See Administrative Procedure 4215 - Criminal History Checks, Employee Self-Reporting of Arrests,
Criminal Charges, CPS Investigation and Findings & Incarceration for additional information governing
self-reporting.
Employee Name: _________________________________________ EIN#: _____________________
PGCPS Job Title/ Location:
___________________________________________________________________________________
Supervisor: ______________________________________________
Contact telephone numbers: Cell/Work/Home:
_____________________________________________________________________________________
PGCPS E-mail address:
_____________________________________________________________________________________
Home Street Address:
____________________________________________________________________________________
City, State, Zip Code:
____________________________________________________________________________________
Date of Alleged Offense:
_____________________________________________________________________________________
Date Reported to PGCPS:
___________________________________________________________________________________
Employee Self-Reporting of Arrests, Criminal Charges,
CPS Investigations and Findings & Incarceration
Attachment to AP 4215
Nature of Charges (Use additional sheets if necessary. See below for list of offenses.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
OFFENSES (list is not exhaustive):
o Distribution of drugs or other controlled substances;
o A sexual offense in the third or fourth degree under § 3-307 or § 3-308 of the Criminal Law
Article of the Maryland Code or an offense under the laws of another state that would
constitute an offense under § 3-307 or § 3-308 of the Criminal Law Article if committed in
Maryland;
o Child sexual abuse under § 3-602 of the Criminal Law Article, or an offense under the laws of
another state that would constitute child sexual abuse under § 3-602 of the Criminal Law Article
if committed in Maryland;
o A crime of violence as defined in § 14-101 of the Criminal Law Article, or an offense under the
laws of another state that would be a violation of § 14-101 of the Criminal Law Article if
committed in Maryland, including: (check all that apply)
o abduction;
o arson in the first degree;
o kidnapping;
o manslaughter, except involuntary manslaughter;
o mayhem;
o maiming;
o murder;
o rape;
o robbery;
o carjacking;
o armed carjacking;
o sexual offense in the first degree;
o sexual offense in the second degree;
o use of a handgun in the commission of a felony or other crime of violence;
o child abuse in the first degree;
o sexual abuse of a minor;
o an attempt to commit any of the crimes described above, specifically:
____________________________________________________;
Employee Self-Reporting of Arrests, Criminal Charges,
CPS Investigations and Findings & Incarceration
Attachment to AP 4215
o continuing course of conduct with a child under § 3-315 of the Criminal Law Article;
o assault in the first degree;
o assault with intent to murder;
o assault with intent to rape;
o assault with intent to rob;
o assault with intent to commit a sexual offense in the first degree;
o assault with intent to commit a sexual offense in the second degree.
o Child Protective Services (CPS):
o Investigation for alleged child abuse, child sexual abuse, and/or neglect – specify:
______________________;
o Indicated finding of alleged child abuse, child sexual abuse, and/or neglect – specify:
______________________;
o Driving while under the influence (DUI);
o Possession of drugs;
o Possession with intent to distribute;
o Other:
______________________________________________________________________________
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Employee Self-Reporting of Arrests, Criminal Charges, CPS Investigations (Prince George's County Public Schools)

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Completed 18 February 2021

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