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ARREST/CONVICTION REPORT AND CERTIFICATION FORM
(under Act 24 of 2011 and Act 82 of 2012)
Section 1. Personal Information
Full Legal Name:
Date of Birth: /
Any former names by which you have been identified:
Section 2. Report of Arrest or Conviction
By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S. §§1-111(e) or (f.1) (“Reportable Offense(s)”). See Instructions on Page 3 of this Form for
a list of Reportable Offenses. If you have none to report, proceed to Section 3 of this form.
Details of Arrests or Convictions
For each arrest for or conviction of any Reportable Offense, specify in the space below (or on additional attachments if necessary) the offense for which you have been arrested or convicted, the date and location of arrest and/or conviction, docket number, and the applicable court.
Section 3. No Arrest or Conviction
By checking this box, I state that I have not been arrested for or convicted of any Reportable
Section 4. Certification
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 failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. §4904, relating to unsworn falsification to authorities.
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This standardized form (PDE-6004) has been developed by the Pennsylvania Department of Education, pursuant to 24 P.S. §1-111(j), to be used by current and prospective employees of public and private schools, intermediate units and area vocational-technical schools for the written reporting by current and prospective employees of any arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) and (f.1).
As required by subsection (j)(2) of 24 P.S. §1-111, this form shall be completed and submitted by all current and prospective employees of a public or private school, intermediate unit or area vocational-technical school. In addition, as required by subsection (j)(4) of 24 P.S. §1-111, this form shall be utilized by current and prospective employees to provide written notice within seventy-two (72) hours after an arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) or (f.1).
Exemption: Any current employee who completed a PDE-6004 on or before December 27, 2011, in compliance with 24 P.S. §§1-111(j)(1) and (2) on that date, and who has not been arrested for or convicted of an offense enumerated under 24 P.S. §§1-111(e) and (f.1) shall not be required to complete an additional form.
In accordance with 24 P.S. §1-111, employees completing this form are required to submit the form to the administrator or other person responsible for employment decisions in a school entity.
If you have questions regarding to whom the form should be sent, please contact your supervisor or the school entity administration office.
PROVIDE ALL INFORMATION REQUIRED BY THIS FORM LEGIBLY IN INK.
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LIST OF REPORTABLE OFFENSES
∙A reportable offense enumerated under 24 P.S. §1-111(e) consists of any of the following:
(1)An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated Statutes:
Chapter 25 (relating to criminal homicide)
Section 2702 (relating to aggravated assault)
Section 2709.1 (relating to stalking)
Section 2901 (relating to kidnapping)
Section 2902 (relating to unlawful restraint)
Section 2910 (relating to luring a child into a motor vehicle or structure)
Section 3121 (relating to rape)
Section 3122.1 (relating to statutory sexual assault)
Section 3123 (relating to involuntary deviate sexual intercourse)
Section 3124.1 (relating to sexual assault)
Section 3124.2 (relating to institutional sexual assault)
Section 3125( relating to aggravated indecent assault)
Section 3126 (relating to indecent assault)
Section 3127 (relating to indecent exposure)
Section 3129 (relating to sexual intercourse with animal)
Section 4302 (relating to incest)
Section 4303 (relating to concealing death of child)
Section 4304 (relating to endangering welfare of children)
Section 4305 (relating to dealing in infant children)
A felony offense under section 5902(b) (relating to prostitution and related offenses)
Section 5903(c) or (d) (relating to obscene and other sexual materials and performances)
Section 6301(a)(1) (relating to corruption of minors)
Section 6312 (relating to sexual abuse of children)
Section 6318 (relating to unlawful contact with minor)
Section 6319 (relating to solicitation of minors to traffic drugs)
Section 6320 (relating to sexual exploitation of children)
(2)An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as
“The Controlled Substance, Drug, Device and Cosmetic Act.”
(3)An offense SIMILAR IN NATURE to those crimes listed above in clauses (1) and (2) under the laws or former laws of:
•the United States; or
•one of its territories or possessions; or
•another state; or
•the District of Columbia; or
•the Commonwealth of Puerto Rico; or
•a foreign nation; or
•under a former law of this Commonwealth.
∙A reportable offense enumerated under 24 P.S. §1-111(f.1) consists of any of the following:
(1)An offense graded as a felony offense of the first, second or third degree, other than one of the offenses enumerated under 24 P.S. §1-111(e), if less than (10) ten years has elapsed from the date of expiration of the sentence for the offense.
(2)An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated under 24 P.S. §1-111(e), if less than (5) five years has elapsed from the date of expiration of the sentence for the offense.
(3)An offense under 75 Pa.C.S. § 3802(a), (b), (c) or (d)(relating to driving under influence of alcohol or controlled substance) graded as a misdemeanor of the first degree under 75 Pa.C.S. § 3803 (relating to grading), if the person has been previously convicted of such an offense and less than (3) three years has elapsed from the date of expiration of the sentence for the most recent offense.