1. Return all completed information to:
       

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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 above, 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

      Everett Public Schools - Human Resources
       ADDRESS

      P.O. Box 2098, Everett       		PHONE

      425-385-4100
       STATE  ZIP

      WA  98213       		FAX

      425-385-4102
      FORM SPI 1588 (Rev. 4/06)

       

       

       

       

       

       

       

       

       

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