KIPP DC School Safety Omnibus Act Data Collection: Employees

Background & Reference Check Information

Due Diligence as required by the School Safety Omnibus Amendment Act of 2018.

Your Name *

First Last

Your Email *

Start Date at KIPP DC *

Current Position at KIPP DC *

Employment History

Please provide the following information for any previous employment in the last 20 years that involved direct interaction with students/children; please add additional roles, as necessary.

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Do you have another former employer to provide? *

No
Yes

Employer *

Contact/Supervisor Name *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Dates of Employment *

Character Reference

Please provide the contact information for at least one character reference.

Name #1 *

First Last

Address *

Street Address Address Line 2 City State ZIP Code

Phone

Email *

Name #2

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Email

Affirmation

PLEASE PROVIDE YOUR ELECTRONIC SIGNATURE BELOW TO AFFIRM THE FOLLOWING: 1. I have never been the subject of any child abuse or sexual misconduct investigation by any employer, state licensing agency, law enforcement agency, or CFSA (or other state’s equivalent) that did not result in a finding that the allegations were false or the alleged incident was not substantiated; 2. I have never been disciplined, discharged, nonrenewed, asked to resign, resigned from or otherwise separated from employment while allegations of child abuse or sexual misconduct were pending or under investigation or due to an adjudication or finding of child abuse or misconduct; 3. I have never had a license, professional license, or certificate suspended, surrendered or revoked while allegations of child abuse or sexual misconduct were pending or under investigation, or due to an adjudication or finding of child abuse or sexual misconduct. 4. I authorize/consent that these employers may disclose my employment history records and I release them from any liability that may arise from the disclosure or release of these records.

YOUR NAME AS LEGALLY-RECOGNIZED ELECTRONIC SIGNATURE *

Today's Date *

KIPP DC School Safety Omnibus Act Data Collection: Employees