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

SCHOOL DISTRICT EMPLOYER

PERSONNEL DEPARTMENT

No prior

school district

employment

STREET ADDRESS

To:

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 180-87 and WAC 180-88. 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

ADDRESS

PHONE

STATE

ZIP

FAX

FORM SPI 1588 (Rev. 6/05)