Mandatory Report Form. This is a Pennsylvania form and can be use in Department Of Education Statewide.
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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 American LegalNet, Inc. www.FormsWorkflow.com 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) American LegalNet, Inc. www.FormsWorkflow.com