MANDATORY REPORT FORM 

The School Laws require school officials to report promptly to the Department of Education the following: 1) an educator who is dismissed for cause; 2) an educator who is charged with a crime involving moral turpitude or some other offense requiring mandatory suspension or revocation; 3) an educator who is convicted of a crime involving moral turpitude or any other offense requiring mandatory suspension or revocation. (24 P.S. §2070.9(b)).

While the above situations are mandatory, the Department of Education strongly encourages school officials to similarly report educators who resign to avoid a dismissal for cause, even if there is no dismissal proceeding, formal charge, or conviction. The Department is especially interested in learning of matters involving danger to students or others in the schools.

Send this completed form, with supporting documentation to: Pennsylvania Department of Education, Office of the Deputy Secretary for Postsecondary and Higher Education, 333 Market Street, 12th Floor, Harrisburg, PA 17126-0333, Attention: Nancy Avolese.

 

1.____SCHOOL ENTITY:
A. Name and Address ________________________________________________________

__________________________________________________________________________

__________________________________________________________________________
B. Contact Person ___________________________________________________________
C. Telephone Number (_____)__________________________________________________
 
2.____COUNTY/STATE WHERE CONDUCT OCCURRED: __________________________
 
3.____EDUCATOR'S INFORMATION:
A. Name __________________________________________________________________
B. Social Security Number _________________________ C. Date of Birth _____________
D. Most Recent Position ______________________________________________________
E. Telephone Number (Home)____________________ (Work)_______________________
F. Home Address (Please complete and check box below)
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

[ ] Address is current_____[ ] Address is most recent but may be inaccurate

 
4.____CURRENT STATUS OF EDUCATOR:
[ ] In classroom_______________________________ [ ] Temporarily Reassigned
[ ] Suspended with pay on _____________ _________ [ ] Resigned on __________

__________________________Date __ _ _ __ __ __ _ _ _ _ _ __ _____________Date

[ ] Suspended without pay on _______________ _____[ ] Dismissed on __________

_____________________________Date ____________________________Date

  
5.____[_] DISMISSED FOR CAUSE OR___[_] RESIGNED IN ORDER TO AVOID
__________________________________ BEING DISMISSED:
 
A. Check the reason(s) the educator was dismissed or would have been dismissed:
   
  [ ] Immorality[ ] Drugs or Narcotics
  [ ] Intemperance[ ] Cruelty
  [ ] Incompetence[ ] Negligence
  [ ] Persistent and Willful[ ] Forged or Altered Certificate
  __Violation of School Laws 
  _ _ _ [ ] Other ___________________________________________
   
   
  B. Briefly describe the facts surrounding the dismissal and the act or behavior
  __ of the educator.
  __ ____________________________________________________________
  __ ____________________________________________________________
  __ ____________________________________________________________
  __ ____________________________________________________________
   
  C. If a dismissal hearing or arbitration hearing was held, indicate the date(s) of
  __ the hearing(s) and the date of the final decision:
  __ ____________________________________________________________
   
  D. Attach the following supporting documentation when applicable:
   
  __ 1. Certified copies of ratings.
  __ 2. Copies of applicable policies and/or directives.
  __ 3. Certified copies of applicable Board minutes.
  __ 4. Copy of educator's resignation, any resignation agreements, and
  ____ evidence of the Board's acceptance of the resignation.
   
  Note: There is no need to forward transcripts. The Department will request copies if necessary. There is no need to forward transcripts. The Department will request copies if necessary.
   
6. CHARGED WITH, OR CONVICTED OF, A CRIME OF MORAL TURPITUDE:
  A. List the crime(s): _________________________________________________________
  B. List the county in which the educator was
  __ charged/convicted________________________________________________________
  C. List the docket number: ___________________________________________________
  D. List the date of the charge/conviction/sentencing: _________________________________
  E. List the name of the district magistrate: _________________________________________
  F. Enclose a copy of any available criminal court documents.
   
  _ ________________________________________ ____ _________________
  _____(Signature of Chief School Administrator) _______________(Date)
   
   
   
  PDE-349 (revised 6/98)