Fillable form to the applicants current and former employers (Pennsylvania Department of Transportation)

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form to the applicants current and former employers (Pennsylvania Department of Transportation)

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COMMONWEALTH OF PENNSYLVANIA
SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE
(Pursuant to Act 168 of 2014)
Instructions
This standardized form has been developed by the Pennsylvania Department of Education, pursuant to Act 168 of 2014, to be used by
school entities and independent contractors of school entities and by applicants who would be employed by or in a school entity in a
position involving direct contact with children to satisfy the Act’s requirement of providing information related to abuse or sexual
misconduct. As required by Act 168, in addition to fulfilling the requirements under section 111 of the School Code and the Child
Protective Services Law (“CPSL”), an applicant who would be employed by or in a school entity in a position having direct contact with
children, must provide the information requested in SECTION 1 of this form and complete a written authorization that consents to and
authorizes the disclosure by the applicant’s current and former employers of the information requested in SECTION 2 of this form. The
applicant shall complete one form for the applicant’s current employer(s) and one for each of the applicant’s former employers that were
school entities or where the applicant was employed in a position having direct contact with children (therefore, the applicant may have
to complete more than one form). Upon completion by the applicant, the hiring school entity or independent contractor shall submit the
form to the applicant’s current and former employers to complete SECTION 2. A school entity or independent contractor may not
hire an applicant who does not provide the required information for a position involving direct contact with children.
Relevant Definitions:
Direct Contact with Children is defined as: “the possibility of care, supervision, guidance or control of children or routine interaction
with children.”
Sexual Misconduct is defined as: “any act, including, but not limited to, any verbal, nonverbal, written or electronic communication or
physical activity, directed toward or with a child or a student regardless of the age of the child or student that is designated to establish
a romantic or sexual relationship with the child or student. Such acts include, but are not limited to: (1) sexual or romantic invitation; (2)
dating or soliciting dates; (3) engaging in sexualized or romantic dialogue; (4) making sexually suggestive comments; (5) self-disclosure
or physical exposure of a sexual, romantic or erotic nature; or (6) any sexual, indecent, romantic or erotic contact with the child or
student.”
Abuse is defined as “conduct that falls under the purview and reporting requirements of the CPSL, 23 Pa.C.S. Ch. 63, is directed
toward or against a child or a student, regardless of the age of the child or student.”
Please Note
A prospective employer that receives any requested information regarding an applicant may use the information for the purpose of
evaluating the applicant’s fitness to be hired or for continued employment and shall report the information as appropriate to the
Department of Education, a state licensing agency, law enforcement agency, child protective services agency, another school entity or
to a prospective employer.
If the prospective employer decides to further consider an applicant after receiving an affirmative response to any of the questions listed
in SECTIONS 1 and 2 of this form, the prospective employer shall request that former employers responding affirmatively to the
questions provide additional information about the matters disclosed and include any related records. The Commonwealth of
Pennsylvania Sexual Misconduct/Abuse Disclosure Information Request can be used to request this follow-up information.
Former employers shall provide the additional information and records within 60 calendar days of the prospective employer’s request.
The completed form and any information or records received shall not be considered public records for the purposes of the Act of
February 14, 2008 (P.L. 6, No. 3) known as the “Right to Know Law.”
The Department of Education shall have jurisdiction to determine willful violations of Act 168 and may, following a hearing, assess a
civil penalty not to exceed $10,000. School entities shall be barred from entering into a contract with an independent contractor who is
found to have willfully violated the provisions of Act 168.
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COMMONWEALTH OF PENNSYLVANIA
SEXUAL MISCONDUCT/ABUSE DISCLOSURE RELEASE
(under Act 168 of 2014)
(Hiring school entity or independent contractor submits this form to ALL current employer(s) and to former employer(s) that
were school entities and/or where the applicant had direct contact with children)
The named applicant is under consideration for a position with our entity. The Pennsylvania General Assembly has determined that
additional safeguards are necessary in the hiring of school employees to ensure the safety of the Commonwealth’s students. The
individual whose name appears below has reported previous employment with your entity. We request you provide the information
requested in SECTION 2 of this form within 20 calendar days as required by Act 168 of 2014.
SECTION 1: APPLICANT CERTIFICATION AND RELEASE (TO BE COMPLETED BY THE APPLICANT EVEN IF THE APPLICANT
HAS NO CURRENT OR PRIOR EMPLOYMENT TO DISCLOSE)
Applicant’s Name (First, Middle, Last):
Any former names by which the Applicant has been identified:
DOB:
Last 4 digits of Applicant’s Social Security Number:
PPID (if applicable):
Approximate dates of employment with the entity listed above:
Position(s) held with the entity:
Pursuant to Act 168, an employer, school entity, administrator, and/or independent contractor that provides information or records about
a current or former employee or applicant shall be immune from criminal liability under the CPSL, the Educator Discipline Act, and from
civil liability for the disclosure of the information, unless the information or records provided were knowingly false. Such immunity shall
be in addition to and not in limitation of any other immunity provided by law or any absolute or conditional privileges applicable to such
disclosure by the virtue of the circumstances of the applicant’s consent thereto. Under Act 168, the willful failure to respond to or
provide the information and records as requested may result in civil penalties and/or professional discipline, where applicable.
To:
Name of Current or Former Employer:
☐
No applicable employment
Street Address:
City, State, Zip:
Fax Number:
Email:
Contact Person:
Title:
3/3
Have you (Applicant) ever:
Yes No Been the subject of an abuse or sexual misconduct investigation by any employer, state licensing agency, law
enforcement agency or child protective services agency (unless the investigation resulted in a finding that the
allegations were false)?
Yes No Been disciplined, discharged, non-renewed, asked to resign from employment, resigned from or otherwise
separated from employment while allegations of abuse or sexual misconduct were pending or under
investigation or due to adjudication or findings of abuse or sexual misconduct?
Yes No Had a license, professional license or certificate suspended, surrendered or revoked while allegations of abuse
or sexual misconduct were pending or under investigation or due to an adjudication or findings of abuse or
sexual misconduct?
By signing this form, I certify under penalty of law that the statements made in this form are correct, complete, and true to the best of
my knowledge. I understand that false statements herein, including, without limitation, any willful failure to disclose the information
required, shall subject me to criminal prosecution under 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities) and to
discipline up to, and including, termination or denial of employment, and may subject me to civil penalties and disciplinary action under
the Educator Discipline Act. I also hereby authorize the above-named employer to release to the entity listed on page 3, the information
requested in SECTION 2 of this form and any related records. I hereby release, waive, and discharge the above-named employer from
any and all liability of any kind that may arise from such disclosure or release of records. I understand that third party vendors may be
used to process this Act 168 pre-employment history review.
________________________________________________ _______________________________
Signature of Applicant Date
SECTION 2: CURRENT/FORMER EMPLOYER VERIFICATION (TO BE COMPLETED BY THE APPLICANT’S CURRENT
EMPLOYER(S) AND ALL FORMER EMPLOYERS THAT WERE SCHOOL ENTITIES AND/OR WHERE THE APPLICANT HAD
DIRECT CONTACT WITH CHILDREN)
Dates of employment of Applicant: __________________________ Contact telephone #:___________________________
To the best of your knowledge, has Applicant ever:
Yes No Been the subject of an abuse or sexual misconduct investigation by any employer, state licensing agency, law
enforcement agency or child protective services agency (unless the investigation resulted in a finding that the
allegations were false)?
Yes No Been disciplined, discharged, non-renewed, asked to resign from employment, resigned from or otherwise
separated from employment while allegations of abuse or sexual misconduct were pending or under
investigation or due to adjudication or findings of abuse or sexual misconduct?
Yes No Had a license, professional license or certificate suspended, surrendered or revoked while allegations of abuse
or sexual misconduct were pending or under investigation or due to an adjudication or findings of abuse or
sexual misconduct?
No records or other evidence currently exists regarding the above questions. I have no knowledge of
information pertaining to the applicant that would disqualify the applicant from employment.
________________________________________________ _______________________________
Former Employer Representative Signature and Title Date
Return all completed information to:
School Entity/Independent Contractor:
Address:
Phone:
City: State: Zip:
Fax: Email:
Contact Person:
Title:
Date Form Received: _________________________ Received by: ______________________________
STEELTON-HIGHSPIRE SCHOOL DISTRICT
250 Reynders Avenue
717-704-3802
Steelton, PA 17113
717-704-3808 / cchisholm@shsd.k12.pa.us
Cynthia Chisholm
Administrative Assistant to the Superintendent
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Completed 26 May 2021

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