4-E - Pre-Service Affidavit for Educational Entities.pdf

PRE-EMPLOYMENT OR PRE-SERVICE AFFIDAVIT FOR EDUCATIONAL ENTITIES

Pursuant to Texas Education Code (TEC) §22A.055, a person applying for employment with or who will act as a service provider for an educational entity (school district, district of innovation, open-enrollment charter school, other charter entity, regional education service center, or shared services arrangement) must submit, using a form adopted by the agency, a pre-employment or pre-service affidavit.

Section 1 - Penalties for Failure to Disclose Required Information

A person commits an offense, a Class B misdemeanor, if the person fails to disclose information required to be disclosed under TEC §22A.055. Additionally, a determination that an employee or person providing services failed to disclose information required to be disclosed by a person under TEC §22A.055 is grounds for termination of employment or service.

Section 2 – Disclosure of Work History and Consent for Release of Records

Have you previously been employed by or acted as a service provider, or are you currently employed by or currently acting as a service provider for a public or private school?

Yes No

Do you consent for release of your prior employment records?

Pursuant to TEC §22A.055, a person applying for employment with or who will act as a service provider for an educational entity must consent for release of the person's employment records.

Yes No

Section 3 – Disclosure of Investigation or Placement on the Do Not Hire Registry

Have you ever been terminated, non-renewed, or discharged from a public or private school?

Yes No

Have you ever resigned, in lieu of being terminated or discharged, from a public or private school?

Yes No

Have you ever been investigated by a law enforcement or child protective services agency for, or charged with, adjudicated for, or convicted of, an offense involving the following conduct described by TEC §22A.051(a)(2)(A), (B), (C), or (D) ?:

• abused or otherwise committed an unlawful act with a student or minor, including by engaging in conduct that involves physical mistreatment or constitutes a threat of violence to a student or minor and that is not justified under Chapter 9, Penal Code, regardless of whether the conduct resulted in bodily injury;

• was involved in or solicited a romantic relationship with or solicited or engaged in sexual contact with a student or minor;

• engaged in inappropriate communications with a student or minor, as defined by board rule;

• failed to maintain appropriate boundaries with a student or minor, as defined by board rule;

Adjudication and conviction refer to a conviction, plea of guilty or no contest (nolo contendre), probation, suspension, or deferred adjudication.

Charge refers to a formal criminal charge as documented by a primary charging instrument (a complaint, information, or indictment) under the Texas Code of Criminal Procedure.

Yes No

Have you ever been investigated by a licensing authority or had a license, certificate, or permit denied, suspended, revoked, or subject to another sanction in this state or another state for conduct described by TEC §22A.051(a)(2)(A), (B), (C), or (D), which is described above?

Yes No

Are you now the subject of an inquiry, disciplinary action, review, or investigation, by any public or private school, by a teacher-licensing agency, by any law enforcement agency, or in the court of Texas or any other state in connection with any alleged misconduct?

Yes No

Have you ever been listed on the Do Not Hire Registry under TEC §22A.151 by the Texas Education Agency.

Yes No

If you answered YES to any question in this section, disclose all relevant facts known to you pertaining to the matter, including, if applicable to the action, whether the allegation was determined to be true or false.

Section 3 – Declaration of Applicant

Name (First, Middle, Last) Date of Birth

Address (House/Unit # and Street Name)

Address (City, State, Zip Code) County

Signature

Date Signed