Washington state sexual misconduct disclosure release




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WASHINGTON STATE SEXUAL MISCONDUCT

DISCLOSURE RELEASE
(District Submits This Form to Previous School District Employer(s))




To:

SCHOOL DISTRICT EMPLOYER

     


 No prior school district employment

PERSONNEL DEPARTMENT

     


STREET ADDRESS

     





CITY, STATE, ZIP

     




The named applicant is under consideration for a position in our district. The Legislature has determined that additional safeguards are necessary in the hiring of school district employees to ensure the safety of Washington’s school children. The individual whose name appears below has had previous employment with your organization. As a former employer, we request you provide the information requested on this form within 20 business days as required by state law (RCW 28A.400). Sexual misconduct definitions are found in WAC 181-87 and WAC 181-88. Your assistance is appreciated.




APPLICANT’S NAME (FIRST, MIDDLE, LAST)

     


FULL NAME WHEN LAST EMPLOYED WITH ORGANIZATION

     


SOCIAL SECURITY NUMBER

     


CERTIFICATE NO.

     


APPROXIMATE DATES OF EMPLOYMENT

     


POSITION(S)

     

I authorize you to release to the school/district listed below, all information related to any acts of sexual misconduct that the school district has made a determination that there is sufficient information to conclude that the abuse or misconduct occurred and that the abuse or misconduct resulted in the employee’s leaving his or her position at the school district. Such information includes copies of all related documents, including any rebuttal documents, in personnel, investigative or other files, in accordance with RCW 28A.400. I release the above employer and employees acting on behalf of the employer from any liability for providing information described in this document.

Applicant Signature Date





This section to be completed by former school district employer(s) only.
 No sexual misconduct materials were found. Was a complaint of sexual misconduct

 Yes, sexual misconduct materials are available. filed with OSPI?  Yes  No

Please contact for more information.

 No record of employment


Former Employer Representative Signature Title Date



Employing School Receipt Date       Received By      



Return all completed information to:




SCHOOL DISTRICT

     





ADDRESS

     


PHONE

     





STATE ZIP

           



FAX

     


FORM SPI 1588 (Rev. 6/07)


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