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)
Name of Current or Former Employer:
☐No applicable employment
Street Address:
City, State, Zip:
Telephone Number:
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 business 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:
Approximate dates of employment with the entity listed above:
Position(s):
Have you (Applicant) ever:
Yes____ |
No_____ |
Been the subject of an abuse or sexual misconduct investigation by any employer, state licensing |
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agency, law enforcement agency or child protective services agency (unless the investigation |
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resulted in a finding that the allegations were false)? |
Yes____ |
No_____ |
Been disciplined, discharged, non-renewed, asked to resign from employment, resigned from or |
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otherwise separated from employment while allegations of abuse or sexual misconduct were |
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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 |
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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 true, correct and complete. I understand that false statements herein, including, without limitation, any willful failure to disclose the information
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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.
________________________________________ |
____________________________________ |
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)
Employing Entity receipt date____________________ |
Received by_______________________ |
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Contact telephone #_________________ |
Dates of employment of Applicant: _______________________________
To the best of your knowledge, has Applicant ever:
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Yes____ |
No_____ |
Been the subject of an abuse or sexual misconduct investigation by any employer, state licensing |
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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? |
___________________________________________ |
_____________________________________ |
Former Employer Representative Signature and Title |
Date |
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 wilful failure to respond to or provide the information and records as requested may result in civil penalties and/or professional discipline, where applicable.
Return all completed information to:
School Entity:
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 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 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 wilful 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 wilfully violated the provisions of Act 168.
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