4112.51 Form 2

4212.51

STATE OF CONNECTICUT

Educational Employer Verification

(in accordance with Public Act 16-67)

Directions for School District/Entity Considering Applicant for Employment: Each local or regional board of education, governing council of a state or local charter school or an interdistrict magnet school operator is required to obtain the information listed on this form from ALL current or former employer(s) of the applicant if such employer was a local or regional board of education, a governing council of a state or local charter school, an interdistrict magnet school operator of if the employment caused the applicant to have contact with children.  Applicants are required under the law to provide a prospective employer with the name, address and telephone number of all current or former employers that meet the above criteria. Information may be collected either through a written communication or telephonically.

Directions for Current/Previous Employer: The applicant listed below is under consideration for a position with the school/district listed below in Section 2. The individual identified below has reported current/previous employment with your organization or contractual services with your organization in a position in which he/she had contact with children. As required by Connecticut General Statutes Section 10-222c, as amended by Public Act 16-67, please provide the information requested in Section 3. In accordance with the provisions of Public Act 16-67, you are required to respond to this request within five business days.

Section 1 - To be completed by the Applicant

Name of applicant

 

Former name(s) (if applicable)

 

Street address

 

City, State, Zip Code

 

Approximate dates of employment with employer listed in Section 3 of this form

 

Position held with employer listed in Section 3 of this form

 

Section 2 - To be completed by Prospective Employer

Name of prospective employer

 

Street address of prospective employer

 

City, State, Zip Code

 

Contact person

 

Telephone number/email address

 

Section 3 - To be completed by the Current/Former Employer

Name of employer

 

Date of receipt of this notice

 

Date of employment of above-named applicant

 

Contact person

 

Telephone number/email address

 

Y         N

[ ]        [ ]  Been the subject of an allegation of abuse or neglect or sexual misconduct for which there is an investigation currently pending with any current or prior employer, state agency or municipal police department or which has been substantiated?

Y         N

[ ]        [ ]  Been disciplined or asked to resign from employment or resigned from or otherwise separated from any employment while an allegation of abuse or neglect or sexual misconduct was pending or under investigation, or due to a substantiation of abuse or neglect or sexual misconduct?

Y         N

[ ]        [ ]  Had a professional or occupational license, certificate, authorization or permit suspended or revoked or ever surrendered such a license, certificate, authorization or permit while an allegation of abuse or neglect or sexual misconduct was pending or under investigation, or due to a substantiation of abuse or neglect or sexual misconduct?

_____________________________________________     _________________

Signature of Superintendent or HR Director                                 Date

Return all completed information to the Prospective Employer listed in Section 2 of this form.

NOTES:

The terms provided below are currently defined in state law as follows. Please note that statutes may be amended from time to time.

Sexual Misconduct - "any verbal, nonverbal, written or electronic communication, or any other act directed toward or with a student that is designed to establish a sexual relationship with the student, including a sexual invitation, dating or soliciting a date, engaging in sexual dialog, making sexually suggestive comments, self-disclosure or physical exposure of a sexual or erotic nature and any other sexual, indecent or erotic contact with a student." Connecticut General Statutes §10-222c(k).

Abuse or neglect - "abuse or neglect as described in Section 46b-120, and includes any violation of Sections 53a-70, 53a-70a, 53a-71, 53a-72a, 53a-72b or 53a-73a." Connecticut General Statutes §10-222c(k).