1. BACKGROUND QUESTIONNAIRE
    BACKGROUND QUESTIONNAIRE
    1. Are you presently under contract?
    ‰
    Yes
    ‰
    No
    If yes, with whom? _________________________________________________________
    What is your present position/Title? ___________________________________________
    2. Are you a former employee of our District?
    ‰
    Yes
    ‰
    No
    3. Have you ever been on a plan of improvement or probation plan or advised that you would be placed
    on such a plan?
    ‰
    Yes
    ‰
    No
    4. Have you ever been placed on leave pending investigation of allegations of misconduct?
    ‰
    Yes
    ‰
    No
    5. Have you ever been the subject of a complaint to the Superintendent of Public Instruction or any other
    disciplinary board or licensing body?
    ‰
    Yes
    ‰
    No
    6. Have you ever resigned or otherwise separated from any employment (inclusive of regular or
    extracurricular positions) while allegations of misconduct on your part were under investigation or in
    order to avoid disciplinary action or nonrenewal by an employer?
    ‰
    Yes
    ‰
    No
    7. Have you ever been discharged or nonrenewed from any employment (inclusive of regular or
    extracurricular positions)?
    ‰
    Yes
    ‰
    No
    8. Have you ever been disciplined for misconduct by an employer?
    ‰
    Yes
    ‰
    No
    9. Are you presently charged with, but not convicted of a crime? (Exclude civil infractions, such as minor
    traffic citations.)
    ‰
    Yes
    ‰
    No
    If yes, enter an explanation of the nature of this charge, place, date, and court. A record will not
    necessarily bar you from District employment.
    ________________________________________________________________________
    Pursuant to RCW 9A.72.085, I declare under the penalty of perjury under the laws of the State of Washington, that
    the foregoing answers and all information included in my application are true, complete and correct. If the
    information provided or answer(s) to any question on the Application or Background Questionnaire change prior to
    my being hired, I agree to immediately notify the Everett Public Schools Human Resources Department of such
    changes. I agree that if I have failed to update the Background Questionnaire or if I have provided false,
    misleading, or incomplete information on the Application or Background Questionnaire, the Everett Public Schools
    may, at its sole discretion, terminate my employment. If such action is taken by the District, I agree that any
    employment contract or employment relationship deemed to exist shall be void from its inception. I further agree
    that if at any time in the future as an applicant I am convicted of any crime, have findings made against me in a civil
    adjudicative proceeding, or become the subject of a complaint made to the Office of the Superintendent of Public
    Instruction, I will immediately notify the Everett Public Schools Human Resources Department.
    Name (please print) _____________________ Signature:_______________________ Date:
    RCW 43.43.845
    Crimes against children -- Sexual offenses under chapter 9A.44 RCW -- Notification of
    conviction or guilty plea of school employee.
    (1) Upon a guilty plea or conviction of a person of any felony crime involving the physical neglect
    of a child under chapter 9A.42 RCW, the physical injury or death of a child under chapter 9A.32
    or 9A.36 RCW (except motor vehicle violations under chapter 46.61 RCW), sexual exploitation of
    a child under chapter 9.68A RCW, sexual offenses under chapter 9A.44 RCW, promoting
    prostitution of a minor under chapter 9A.88 RCW, or the sale or purchase of a minor child under
    RCW 9A.64.030, the prosecuting attorney shall notify the state patrol of such guilty pleas or
    convictions.
    (2) When the state patrol receives information that a person has pled guilty to or been convicted
    of one of the felony crimes under subsection (1) of this section, the state patrol shall transmit that
    information to the superintendent of public instruction. It shall be the duty of the superintendent of
    public instruction to identify whether the person holds a certificate or permit issued under chapters
    28A.405 and 28A.410 RCW or is employed by a school district, and provide this information to
    the Washington professional educator standards board and the school district employing the
    individual who pled guilty or was convicted of the crimes identified in subsection (1) of this
    section.

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