S ELF -D ISCLOSURE OF A R EPORTABLE O FFENSE F ORM I NSTRUCTIONS
In accordance with Section 6344.3(g) of the Pennsylvania Child Protective Services Law, employees and volunteers of the College who work or serve in positions that have direct contact with children, or who are otherwise covered by and subject to the clearance requirements set forth in Board Policy II.07 – Protection of Children, must provide the College with written notice in the event that they are arrested for or convicted of an offense enumerated in the attached “Reportable Offense” list or in the event that they are named as a perpetrator in a founded or indicated report of child abuse. Written notice must be provided, utilizing this form, within 72 hours of the arrest or conviction, or from receipt of notification that the person has been listed as a perpetrator in a founded or indicated report of child abuse in the statewide database. Willful failure to make a written notification as required herein may result in disciplinary action, including termination of employment or assignment. Violation(s) for failure to report may also result in referral to law enforcement for criminal prosecution under the CPSL. Individuals completing this form are required to submit the form to the Office of Human Resources. Should an individual be unsure about the applicability of his/her arrest or conviction as a Reportable Offense, it is the individual’s responsibility to disclose the information to the Office of Human Resources for further review. P ERSONAL I NFORMATION Full Legal Name: ___________________________________ Date of Birth:___________________________ Last First MI Community College of Allegheny County Employee Identification Number: _________________________ Other names you have used or by which you have been identified (include maiden names): R EPORT OF A RREST OR C ONVICTION By checking this box, I report that I have been arrested for or convicted of an offense or offenses on the “Reportable Offense(s)” list included with this form, or have been named as perpetrator in a founded or indicated report of child abuse. For any arrest or conviction of any Reportable Offense, specify in the space below (or on additional attachments if necessary) the crime for which you have been arrested or convicted, the date and location of arrest and/or conviction, and the applicable court. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ 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 disciplinary action, up to and including termination, as well as possible criminal prosecution. I agree to release and hold harmless Community College of Allegheny County from all liabilities associated with information or actions associated with this information. Signature: ______________________________________________________ Date: ______________________
Appendix C
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