Fillable Professional Fitness Explanation Form (California)

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Professional Fitness Explanation Form (California)

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Commission on Teacher Credentialing
OA-EF 9/2013 Page 1 of 7
Professional Fitness Explanation Form
The Professional Fitness section of each application contains six questions. If you
answered yes to any question, you must submit an Explanation Form for each
incident, even if the incident was previously disclosed. If you are reporting convictions,
each conviction must be disclosed on a separate explanation form.
Special note regarding criminal convictions or pending criminal charges:
You are required to disclose all misdemeanor or felony criminal convictions including
those based on a plea of no contest. You must disclose a conviction no matter how
much time has passed, even if the case has been dismissed pursuant to Penal Code
section 1203.4. In accordance with Health & Safety Code sections 11361.5 and
11361.7, you may omit misdemeanor marijuana-related convictions that occurred more
than two years prior to this application, except convictions involving concentrated
cannabis, which must be disclosed regardless of the date of such a conviction.
If you are disclosing a conviction, employer action, investigation, or adverse action that
you previously disclosed to the Commission, you must provide an explanation but you
do not need to submit additional documentation. Your explanation must include dates,
location, type of action taken, what you were charged with and convicted of, and agency
and/or employer name.
Warning: Failure to disclose any required information is falsification of your application
and the Commission may reject or deny your application or take disciplinary action
against your credential. Failure to submit the required explanation or documentation
may result in your application being rejected.
Using this form:
This form contains five sections. Determine which sections apply to each incident and
complete the required information.
If you answered yes to… Complete the following section of this form…
(click the section letter below to be transported to that section)
Question a Section A
Question b Section B
Question c Section C
Question d Section D
Question e, f Section E
Commission on Teacher Credentialing
OA-EF 9/2013 Page 2 of 7
Section A: Required information for yes answer to Professional Fitness Question a.
NOTE: You must provide copies of the following documents regarding the action below:
district investigation reports, police reports, Statement of Charges, Accusations,
request for hearing, final decision, letter of resignation or retirement, settlement
agreements, and/or any other related documents. Failure to provide
documentation will result in your application being denied.
For question a, indicate the action taken:
Dismissed Effective date:
Retired Effective date:
Resigned Effective date:
Non-reelected Effective date:
Suspended without pay Effective dates:
Name of employer at time of
action:
Address:
Telephone
number:
Contact person
(if known):
Describe in detail the incident(s) that resulted in the above action (attach additional
sheets if necessary):
Commission on Teacher Credentialing
OA-EF 9/2013 Page 3 of 7
Section B: Required information for yes answer to Professional Fitness Question b.
NOTE: You must provide a copy of the investigative report and a certified copy of the
court docket regarding the incident(s) below. Failure to provide documentation
will result in the rejection of your application.
Was the conviction dismissed or expunged pursuant to California Penal Code section
1203.4 or if an out-of-state conviction, that jurisdiction’s comparable statute? If yes,
provide a certified copy of the dismissal.
Was a felony reduced to a misdemeanor under California Penal Code section 17(b), or
if an out-of-state conviction, that jurisdiction’s comparable statute? If yes, provide a
certified copy of the reduction.
Date of conviction:
Date of offense:
List the code section(s) violated, including whether each count was a misdemeanor or
a felony:
Location of offense:
Name of law enforcement agency:
Jurisdiction (name of court):
Convicted by:
Jury trial
Guilty plea
Court trial
No contest or nolo contendere plea
Sentence and conditions of probations, if any:
Describe the incident(s) leading to your arrest and conviction in detail (attach additional
sheets if necessary):
Commission on Teacher Credentialing
OA-EF 9/2013 Page 4 of 7
Section C: Required information for yes answer to Professional Fitness Question c.
NOTE: You must provide a copy of the investigative report and a certified copy of the
court docket (if any) regarding the incident(s) below. Failure to provide
documentation will result in the rejection of your application.
Provide an explanation of inquiry or investigation:
What is the current status of the inquiry or investigation
Ongoing (when was the investigation started):
Completed (when):
Name of agency, department, or law enforcement
agency conducting the inquiry or investigation:
Jurisdiction (name of court):
Were children involved:
No
Yes
If yes, indicate how:
Did the incident(s) occur on school grounds:
No
Yes
If yes, what school and school district:
Describe the incident(s) resulting in the inquiry or investigation in detail (attach
additional sheets if necessary):
Commission on Teacher Credentialing
OA-EF 9/2013 Page 5 of 7
Section D: Required information for yes answer to Professional Fitness Question d.
NOTE: You must provide a copy of the investigative report and a certified copy of the
court docket (if any) regarding the incident(s) below. Failure to provide
documentation will result in the rejection of your application.
List the pending charges, including whether each count is a misdemeanor or felony:
In what jurisdiction (court) are the charges pending?
Date(s) of alleged criminal conduct
Name of arresting or investigating agency:
Were children involved: No Yes
If yes, indicate how:
Did the incident(s) occur on school grounds: No Yes
If yes, what school and school district:
Describe the incident(s) resulting in the filing of these charges in detail (attach
additional sheets if necessary):
Commission on Teacher Credentialing
OA-EF 9/2013 Page 6 of 7
Section E: Required information for yes answer to Professional Fitness Question e or f.
NOTE: You must provide a copy of any documents provided to you by the agency that
took the action described below. Failure to provide documentation will result in
the rejection of your application.
List the applicable license(s) or credential(s):
License number(s):
Agency’s name:
Address:
Telephone
number:
Contact person
(if known):
Location of misconduct:
Were children involved:
No
Yes
If yes, indicate how:
Action(s) taken:
Private Admonition
Date:
Public Reproval
Date
Suspension
Dates:
How Long?
Fine
Date:
Amount?
Revocation
Date:
Denial of application
Date:
- Were you subsequently granted?
NO
YES
When?
Probation (provide the term)
Other Explain:
Commission on Teacher Credentialing
OA-EF 9/2013 Page 7 of 7
Did the incident(s) occur on school grounds:
No
Yes
If yes, what school and school district:
Describe the incident(s) resulting in the inquiry or investigation in detail (attach
additional sheets if necessary):
Mail all documents to:
Commission On Teacher Credentialing
Division of Professional Practices
1900 Capitol Avenue
Sacramento, CA 95811-4213
Please use the following “DPP Document Submission Form,” which will assist DPP staff
in processing your application in a timely fashion.
50-day deadline does not apply: Education Code section 44350 requires the
Commission to process an application within 50 business days of receipt. The timeline
pertains to all applications whether submitted online or by paper through the U.S mail.
The only exceptions to the 50-day processing timeline are applications submitted by
individuals who must undergo a professional fitness review.
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Completed 17 August 2021

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