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Mandatory Report Form. This is a Pennsylvania form and can be use in Department Of Education Statewide.
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Tags: Mandatory Report Form, Pennsylvania Statewide, Department Of Education
MANDATORY REPORT FORM
The School Laws require school officials to report promptly to the Department of Education the
following: 1) an educator who is dismissed for cause; 2) an educator who is charged with a
crime involving moral turpitude; 3) an educator who is convicted of a crime involving moral
turpitude or any other offense requiring mandatory suspension or revocation. (24 P.S.
§2070.9(b)).
While the above situations are mandatory, the Department of Education strongly
encourages school officials to similarly report educators who resign to avoid dismissal
for cause, even if there is no dismissal proceeding, formal charge, or conviction. The
Department is especially interested in learning of matters involving danger to students
or others in the schools.
Send this completed form, with supporting documentation to: Pennsylvania
Department of Education, Office of the Deputy Secretary for Postsecondary and Higher
Education, 333 Market Street, 12th Floor, Harrisburg, PA 17126-0333.
1.
SCHOOL ENTITY:
A. Name and Address: ______________________________________________________
_______________________________________________________________________
_______________________________________________________________________
B. Contact Person: _________________________________________________________
C. Telephone Number: ______________________________________________________
2.
COUNTY/STATE WHERE CONDUCT OCCURRED: _________________________
3.
EDUCATOR'S INFORMATION:
A. Name: _______________________________________________________________
B. Social Security Number: _________________________________________________
C. Date of Birth: __________________________________________________________
D. Most Recent Position: ____________________________________________________
E. Telephone Number (Home): _____________________ (Work): __________________
F. Home Address: _________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
4.
CURRENT STATUS OF EDUCATOR:
[ ] In classroom
[ ] Suspended with pay on __________
Date
[ ] Suspended without pay on __________
Date
[ ] Temporarily Reassigned
[ ] Resigned on __________
Date
[ ] Dismissed on _________
Date
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MANDATORY REPORT FORM
5. [ ] DISMISSED FOR CAUSE OR [ ] RESIGNED IN ORDER TO AVOID BEING DISMISSED:
A. Check the reason(s) the educator was dismissed or would have been dismissed:
[
[
[
[
] Immorality
] Intemperance
] Incompetence
] Persistent and Willful
Violation of School Laws
[ ] Other:
[
[
[
[
] Drugs or Narcotics
] Cruelty
] Negligence
] Forged or Altered Certificate
B. Briefly describe the facts surrounding the dismissal and the act or behavior of the
educator.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
C. If a dismissal hearing or arbitration hearing was held, indicate the date(s)
of the hearing(s) and the date of the final decision:
_______________________________________________________________________
D. Attach the following supporting documentation when applicable:
1.
2.
3.
4.
Certified copies of ratings.
Copies of applicable policies and/or directives.
Certified copies of applicable Board minutes.
Copy of educator’s resignation, any resignation agreements, and evidence of the
Board’s acceptance of the resignation.
Note: There is no need to forward transcripts. The Department will request copies if necessary.
6.
CHARGED WITH, OR CONVICTED OF, A CRIME OF MORAL TURPITUDE:
A. List the crime(s): ________________________________________________________
B. List the county in which the educator was charged/convicted: ____________________
C. List the docket number: ___________________________________________________
D. List the date of the charge/conviction/sentencing: _____________________________
E. List the name of the district magistrate: _____________________________________
F. Enclose a copy of any available criminal court documents.
__________________________________________
(Signature of Chief School Administrator)
____________
(Date)
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