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Iowa Employment Law Criminal Background

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					Iowa City Community School District                                                                 Clerical Application
509 S. Dubuque St.                                                                                   **Application valid for 6 months**
Iowa City, IA 52240


Name                                                                                                  Date

Address                                                              City                             State                Zip

Phone                                            Phone                                                Desired Number of Hours
                   Home                                                  Work                         Per Day:

Social Security Number
                                                                                                      Maximum            Minimum

Position Desired                                                                                      Computer Experience:


Building Desired                                                                                              List Software Programs
                          (Specific Building or Any Building with Vacant Clerical Position)
                                                                                                      Typing Speed:                WPM
EDUCATION:

High School                                                                                   City/State

College and Major                                                                             City/State

Special Training                                                                              City/State

Other                                                                                         City/State


WORK EXPERIENCE:


Employer                                                  Type of Business & Location                                       Begin/End Dates


Position/Duties




Employer                                                  Type of Business & Location                                       Begin/End Dates


Position/Duties




Employer                                                  Type of Business & Location                                       Begin/End Dates


Position/Duties




Employer                                                  Type of Business & Location                                       Begin/End Dates


Position/Duties
REFERENCES:


Name                                     Address                                  Telephone                   Position



Name                                     Address                                  Telephone                   Position



Name                                     Address                                  Telephone                   Position



Name                                     Address                                  Telephone                   Position



Would you work as a substitute secretary if called upon?                                       Yes              No

Indicate your familiarity with the Iowa City Community School District:



Veteran’s Statement:


Are you a veteran of the US Armed Services?                                                    Yes              No

Criminal Investigation Statement:


Have you ever been convicted of a felony or for any offense involving moral turpitude?         Yes              No
If yes, please explain.




Have you ever been convicted of, or entered a plea regarding any criminal offense that         Yes              No
involved inappropriate contact with, or treatment of a minor? If yes, please explain on a separate sheet.

I authorize the District to conduct a complete criminal check regarding my background and further authorize all government
agencies, departments, bureaus, or related entities to release any and all information regarding my criminal history, if any,
and also agree to prepare and sign any other form necessary to complete a criminal background check. Prior criminal
convictions do not necessarily disqualify an applicant from employment.
                                                                                               Yes              No
By my signature, I promise that the information provided in this employment application and accompanying resume is true
and complete, and that I understand that any false information or significant omissions may disqualify me from further
consideration for employment, and may be justification for my dismissal from employment if discovered at a later date. I
agree to immediately notify the school district if I should be convicted of a felony, or any crime involving dishonesty,
mistreatment of a minor, or a breach of trust while my application is pending, or during my period of employment, if hired.




Date                                     Legal Signature of Applicant




Applicants are considered for all positions without regard to race, creed, color, religion, national origin, gender, age,
marital status, sexual orientation, gender identity, veteran status, disability, or socioeconomic status in its
educational programs, activities, or employment practices.
If you believe you have been discriminated against or treated unjustly in ICCSD hiring or employment
practices, please contact the Equity Director at 509 S. Dubuque Street, 319-688-1000.




                                                       Agreement
I hereby certify that the above information, to the best of my knowledge, is true, accurate and complete: Any
misrepresentation or willful omissions of fact shall be sufficient cause for disqualification of this application or
termination of employment. I authorize verification of any of this information. I authorize all current and former
employers to release any information concerning my background. I understand that this application is not a
contract of employment. In accepting this assignment, if hired, I understand this position is an at-will position. At
any time the district may discharge an at-will employee for any legal reason or no reason at all.




Signature                                                                 Date
                                         CONFIDENTIAL INFORMATION
                                                 (Clerical)


Name __________________________________________                 Social Security # ________________________

The Iowa City Community School District is an equal opportunity employer. We are required annually to report
statistical summaries of information to the Board of Directors and the Equal Employment Opportunity
Commission. Completion of this form is optional.

For our records, we ask that you complete the following information.

1.     (Please Check)

       __________A.           Asian or Pacific Islander

       __________B.           Black, not of Hispanic origin

       __________C.           Hispanic

       __________D.           American Indian or Alaskan Native

       __________E.           White, not of Hispanic origin.

2.     __________Male         __________Female

3.     __________Age

4.     Handicapping condition ______________________________________________________________
       Federal law obligates an employer to provide reasonable accommodation for the known disabilities of
       applicants, unless doing so would pose and undue hardship on the employer.

5.     Veteran status______________________________________________________________________

6.     Position applied for __________________________________________________________________

7.     Please check the source from which you learned of this position:

       __________A.           Professional/university placement office

       __________B.           Personal contact with the Iowa City Community School District Human Resources
                              Office

       __________C.           Written correspondence with the Iowa City Community School District Human
                              Resources Office

       __________D.           Iowa City Community School District web site or another company sponsored web
                              site

       __________E.           Advertisement in newspaper. Please list the name of the newspaper in which you
                              saw the advertisement __________________________________________.

In conformity with federal legislation related to the equality of persons, the Iowa City Community School District
does not consciously discriminate in the educational programs or activities including employment therein and
admission thereto.
                                     Iowa City Community
                                        School District
Lane Plugge, Ph.D.                                                                    509 S. Dubuque St.
Superintendent                                                                        Iowa City, IA 52240
Fax (319) 688-1009                                                                    Tel (319) 688-1000




Dear Applicant:

Attached are two types of forms that the Iowa City Community School District asks that you complete
and return with your application.


1.     The first is a release allowing us to conduct a criminal background investigation. Please
       complete the attached form(s). Fill in all blanks marked by an "x", sign at the bottom of the page
       (do not sign on line for "Requestor"), date and return it with your application. You will note more
       than one form is attached, as you will need to fill out one form for every surname you've
       held. If more forms are needed than what is provided, please contact the Human
       Resources Department at the phone number above.

2.     The second is a release allowing us to contact the Central Abuse Registry to check whether a
       candidate recommended for hire is named as having abused a child. Please complete the
       blanks marked by an "x". Only one form per applicant is needed for this check.

All candidates who are selected for recommended hire undergo a criminal background check. The
school district will not conduct a criminal background check(s) for unsuccessful candidates. The
attached form(s) will be kept in a location separate from your application.
                                                                                    ACCOUNT NUMBER:                9749- F


                                            STATE OF IOWA
                              NON-LAW ENFORCEMENT RECORD CHECK REQUEST
                                               FORM A

TO:      Iowa Division of Criminal Investigation                FROM:       Iowa City Community School District
         Bureau of Identification
         Wallace State Office Building                                      509 S. Dubuque St.
         Des Moines, IA 50319
         (515) 281-5138 (Voice - Days)                                      Iowa City, IA 52240
         (515) 281-4776 (Voice - Evenings)
         (515) 242-6876 (Fax)                                               (319) 688-1009 (Fax)

                                                                            (319) 688-1000 (Phone)




I am requesting an IOWA CRIMINAL HISTORY check on:

(Type or Print Legibly)
                                                         REQUEST


X                                      X                                        X
Last Name (Mandatory)                  First Name (Mandatory)                   Middle Name (Recommended)


X                                      X                                        X
Date of Birth (Mandatory)              Sex (Mandatory)                          Social Security Number (Recommended)




Signature of Requestor


There is a separate Form “A” required for each last name submitted

(DCI Use Only)
                                                         RESULTS


As of                                  , a name and date of birth check revealed:
                      Date


CCH record attached           No CCH record found                           DCI initials


                                                          Waiver

I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the
Division of Criminal Investigation. Any information maintained by the DCI may be released as allowed by law.



X                                                                       X
Signature                                                               Date

Form No. 595-1489 (4/99)
                                                                                    ACCOUNT NUMBER:                9749- F


                                            STATE OF IOWA
                              NON-LAW ENFORCEMENT RECORD CHECK REQUEST
                                               FORM A

TO:      Iowa Division of Criminal Investigation                FROM:       Iowa City Community School District
         Bureau of Identification
         Wallace State Office Building                                      509 S. Dubuque St.
         Des Moines, IA 50319
         (515) 281-5138 (Voice - Days)                                      Iowa City, IA 52240
         (515) 281-4776 (Voice - Evenings)
         (515) 242-6876 (Fax)                                               (319) 688-1009 (Fax)

                                                                            (319) 688-1000 (Phone)




I am requesting an IOWA CRIMINAL HISTORY check on:

(Type or Print Legibly)
                                                         REQUEST


X                                      X                                        X
Last Name (Mandatory)                  First Name (Mandatory)                   Middle Name (Recommended)


X                                      X                                        X
Date of Birth (Mandatory)              Sex (Mandatory)                          Social Security Number (Recommended)




Signature of Requestor


There is a separate Form “A” required for each last name submitted

(DCI Use Only)
                                                         RESULTS


As of                                  , a name and date of birth check revealed:
                      Date


CCH record attached           No CCH record found                           DCI initials


                                                          Waiver

I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the
Division of Criminal Investigation. Any information maintained by the DCI may be released as allowed by law.



X                                                                       X
Signature                                                               Date

Form No. 595-1489 (4/99)
                                                                                    ACCOUNT NUMBER:                9749- F


                                            STATE OF IOWA
                              NON-LAW ENFORCEMENT RECORD CHECK REQUEST
                                               FORM A

TO:      Iowa Division of Criminal Investigation                FROM:       Iowa City Community School District
         Bureau of Identification
         Wallace State Office Building                                      509 S. Dubuque St.
         Des Moines, IA 50319
         (515) 281-5138 (Voice - Days)                                      Iowa City, IA 52240
         (515) 281-4776 (Voice - Evenings)
         (515) 242-6876 (Fax)                                               (319) 688-1009 (Fax)

                                                                            (319) 688-1000 (Phone)




I am requesting an IOWA CRIMINAL HISTORY check on:

(Type or Print Legibly)
                                                         REQUEST


X                                      X                                        X
Last Name (Mandatory)                  First Name (Mandatory)                   Middle Name (Recommended)


X                                      X                                        X
Date of Birth (Mandatory)              Sex (Mandatory)                          Social Security Number (Recommended)




Signature of Requestor


There is a separate Form “A” required for each last name submitted

(DCI Use Only)
                                                         RESULTS


As of                                  , a name and date of birth check revealed:
                      Date


CCH record attached           No CCH record found                           DCI initials


                                                          Waiver

I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the
Division of Criminal Investigation. Any information maintained by the DCI may be released as allowed by law.




X                                                                       X
Signature                                                               Date

Form No. 595-1489 (4/99)
                                                            Iowa Department of Human Services
                                             REQUEST FOR CHILD ABUSE INFORMATION
Persons or agencies with authorized access to child abuse information must use this form to request information about a
registered child abuse report. Complete a separate form for each family or individual.
SECTION I: To be completed by the person or agency requesting the information.
Requester: Last          First            or Agency Name                                                             Telephone Number
                                                              Iowa City Community School District                    (319) 688-1000
Street                                                                                  City                         State        Zip Code
509 S. Dubuque Street                                                                   Iowa City                    IA           52240
Relationship to the persons listed in Section II or III:
Employer
I have read and understand the legal provisions for handling child abuse information which are printed on the back of this
form. I understand that this request will not be approved unless I have authorized access.
Signature of Requester                                                                  Date


Complete Section II if the purpose of this record check is employment, licensing or registration, or payment approval.
SECTION II: List the name and address of the person whose record is being checked.
Last                         First                 Middle    Birth Date                                              Social Security Number

Street                                                               City                      County                State        Zip Code

List maiden name, any previous married names, and any alias:


Complete Section III if the request is for a copy of the written summary of the abuse investigation or assessment.
SECTION III: Request for written summary.
Parent’s Name(s): Last        First                                    Middle    County                 Birth Date           Social Security Number



Street                                                                           City                                State        Zip Code

List maiden name, any previous married names, and any alias:

Children’s Name(s) (Attach additional pages if necessary):
Last                                  First                            Middle    County                 Birth Date           Social Security Number




SECTION IV: Registry or designee decision.

     This request for information is approved.
     This request for information is denied because:
Signature                                                                               Date

470-0643 (Rev. 4/00)                             Copy 1: Central Registry or Designee           Copy 2: Requester            Copy 3: County Office
                       LEGAL PROVISIONS FOR HANDLING CHILD ABUSE INFORMATION
                       Redissemination of Child Abuse Information (Iowa Code 235A.17)

A person, agency, or other recipient of child abuse information shall not redisseminate (release) this
information, except that redissemination is permitted when ALL of the following conditions apply:
 The redissemination is for official purposes in connection with prescribed duties or, in the case of a
  health practitioner, pursuant to professional responsibilities.
 The person to whom such information would be redisseminated would have independent access to
  the same information under Iowa Code Section 235A.15.
 A written record is made of the redissemination, including the name of the recipient and the date and
  purpose of the redissemination.
 The written record is forwarded to the Central Abuse Registry within 30 days of the redissemination.

                                   Criminal Penalties (Iowa Code 235A.21)

A person is guilty of a criminal offense when the person:
 Willfully requests, obtains, or seeks to obtain child abuse information under false pretense, or
 Willfully communicates or seeks to communicate child abuse information to any agency or person
  except in accordance with Iowa Code Sections 235A.15 and 235A.17, or
 Is connected with any research authorized pursuant to Iowa Code Section 235A.15 and willfully
  falsifies child abuse information or any records relating to child abuse.

Upon conviction for each offense, the person shall be punished by a fine of up to $1,000 or
imprisonment for not more than two years, or both fine and imprisonment.

Any person who knowingly, but with criminal purposes, communicates or seeks to communicate child
abuse information except in accordance with Iowa Code Sections 235A.15 and 235A.17 shall for each
such offense be fined not more than $100 or be imprisoned not more than ten days.

Any reasonable grounds for belief that a person has violated any provision of Iowa Code Chapter 235A
shall be grounds for the immediate withdrawal of any authorized access that person might otherwise
have to child abuse information.


                         REQUESTS FOR CORRECTION OF A CHILD ABUSE REPORT

To request correction of a child abuse report, please submit a request in writing to: Central Abuse
Registry, Attn: Registry Review, 5th Fl, 1305 E Walnut St, Des Moines, Iowa 50319-0114. You will be
notified in writing of the Registry decision whether to grant review of a report. If you disagree with this
decision, the written notice will explain how you may request an administrative hearing about the report
and its conclusions. Iowa Code Section 235A.19

470-0643 (Rev. 4/00)               Copy 1: Central Registry or Designee   Copy 2: Requester   Copy 3: County Office

				
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Description: Iowa Employment Law Criminal Background document sample