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The Act 24 PDE 6004 form is an important document for both current and prospective employees in Pennsylvania's educational institutions, including public and private schools, intermediate units, and area vocational-technical schools. This standardized form has been created to ensure that all individuals report their criminal history accurately. It guides users to provide essential personal information, including their full legal name and any former names, alongside details of any arrests or convictions. Section 2 specifically focuses on documenting reportable offenses, which include serious crimes outlined in Pennsylvania law. Individuals must specify the offense, date, location, and relevant court information for any reportable offenses they may have. If an individual has had no such arrests or convictions, they can indicate this in Section 3. The form also includes a certification section, where individuals verify the accuracy of their disclosures, understanding the legal implications of providing false information. It is crucial to submit this form within a specified timeframe after an arrest or conviction, as failure to do so may result in legal consequences. Clarity in the reporting process helps maintain a safe environment for students and staff in Pennsylvania's educational settings.

Act 24 Pde 6004 Example

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ARREST/CONVICTION REPORT AND CERTIFICATION FORM

(under Act 24 of 2011 and Act 82 of 2012)

Section 1. Personal Information

Full Legal Name:

Date of Birth: /

Any former names by which you have been identified:

/

Section 2. Report of Arrest or Conviction

By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S. §§1-111(e) or (f.1) (“Reportable Offense(s)”). See Instructions on Page 3 of this Form for

a list of Reportable Offenses. If you have none to report, proceed to Section 3 of this form.

Details of Arrests or Convictions

For each arrest for or conviction of any Reportable Offense, specify in the space below (or on additional attachments if necessary) the offense for which you have been arrested or convicted, the date and location of arrest and/or conviction, docket number, and the applicable court.

Section 3. No Arrest or Conviction

By checking this box, I state that I have not been arrested for or convicted of any Reportable

Offense.

Section 4. Certification

By signing this form, I certify under penalty of law that the statements made in this form are true, correct and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. §4904, relating to unsworn falsification to authorities.

Signature

Date

PDE-6004 (8/28/2012)

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INSTRUCTIONS

This standardized form (PDE-6004) has been developed by the Pennsylvania Department of Education, pursuant to 24 P.S. §1-111(j), to be used by current and prospective employees of public and private schools, intermediate units and area vocational-technical schools for the written reporting by current and prospective employees of any arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) and (f.1).

As required by subsection (j)(2) of 24 P.S. §1-111, this form shall be completed and submitted by all current and prospective employees of a public or private school, intermediate unit or area vocational-technical school. In addition, as required by subsection (j)(4) of 24 P.S. §1-111, this form shall be utilized by current and prospective employees to provide written notice within seventy-two (72) hours after an arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) or (f.1).

Exemption: Any current employee who completed a PDE-6004 on or before December 27, 2011, in compliance with 24 P.S. §§1-111(j)(1) and (2) on that date, and who has not been arrested for or convicted of an offense enumerated under 24 P.S. §§1-111(e) and (f.1) shall not be required to complete an additional form.

In accordance with 24 P.S. §1-111, employees completing this form are required to submit the form to the administrator or other person responsible for employment decisions in a school entity.

If you have questions regarding to whom the form should be sent, please contact your supervisor or the school entity administration office.

PROVIDE ALL INFORMATION REQUIRED BY THIS FORM LEGIBLY IN INK.

PDE-6004 (8/28/2012)

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LIST OF REPORTABLE OFFENSES

A reportable offense enumerated under 24 P.S. §1-111(e) consists of any of the following:

(1)An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated Statutes:

Chapter 25 (relating to criminal homicide)

Section 2702 (relating to aggravated assault)

Section 2709.1 (relating to stalking)

Section 2901 (relating to kidnapping)

Section 2902 (relating to unlawful restraint)

Section 2910 (relating to luring a child into a motor vehicle or structure)

Section 3121 (relating to rape)

Section 3122.1 (relating to statutory sexual assault)

Section 3123 (relating to involuntary deviate sexual intercourse)

Section 3124.1 (relating to sexual assault)

Section 3124.2 (relating to institutional sexual assault)

Section 3125( relating to aggravated indecent assault)

Section 3126 (relating to indecent assault)

Section 3127 (relating to indecent exposure)

Section 3129 (relating to sexual intercourse with animal)

Section 4302 (relating to incest)

Section 4303 (relating to concealing death of child)

Section 4304 (relating to endangering welfare of children)

Section 4305 (relating to dealing in infant children)

A felony offense under section 5902(b) (relating to prostitution and related offenses)

Section 5903(c) or (d) (relating to obscene and other sexual materials and performances)

Section 6301(a)(1) (relating to corruption of minors)

Section 6312 (relating to sexual abuse of children)

Section 6318 (relating to unlawful contact with minor)

Section 6319 (relating to solicitation of minors to traffic drugs)

Section 6320 (relating to sexual exploitation of children)

(2)An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as

“The Controlled Substance, Drug, Device and Cosmetic Act.”

(3)An offense SIMILAR IN NATURE to those crimes listed above in clauses (1) and (2) under the laws or former laws of:

the United States; or

one of its territories or possessions; or

another state; or

the District of Columbia; or

the Commonwealth of Puerto Rico; or

a foreign nation; or

under a former law of this Commonwealth.

A reportable offense enumerated under 24 P.S. §1-111(f.1) consists of any of the following:

(1)An offense graded as a felony offense of the first, second or third degree, other than one of the offenses enumerated under 24 P.S. §1-111(e), if less than (10) ten years has elapsed from the date of expiration of the sentence for the offense.

(2)An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated under 24 P.S. §1-111(e), if less than (5) five years has elapsed from the date of expiration of the sentence for the offense.

(3)An offense under 75 Pa.C.S. § 3802(a), (b), (c) or (d)(relating to driving under influence of alcohol or controlled substance) graded as a misdemeanor of the first degree under 75 Pa.C.S. § 3803 (relating to grading), if the person has been previously convicted of such an offense and less than (3) three years has elapsed from the date of expiration of the sentence for the most recent offense.

PDE-6004 (8/28/2012)

Form Characteristics

Fact Name Details
Governing Laws This form is governed by Act 24 of 2011 and Act 82 of 2012, as recorded in 24 P.S. §§1-111.
Purpose The PDE-6004 form is used by individuals to report any arrests or convictions related to specific offenses required for employment in schools.
Submission Requirement Current and prospective employees must complete and submit this form within 72 hours of an arrest or conviction for a reportable offense.
Certification By signing the form, the individual certifies that all statements made are true, with penalties for false reporting outlined under 18 Pa.C.S. §4904.

Guidelines on Utilizing Act 24 Pde 6004

Completing the Act 24 PDE 6004 form is an important task for anyone involved with public or private schools in Pennsylvania. This form ensures that the necessary information related to arrests or convictions is reported promptly and accurately. Following these steps will help streamline the process and ensure compliance with the legal requirements.

  1. Start by entering your full legal name in the designated space at the top of the form.
  2. Next, provide your date of birth in the format specified on the form.
  3. Indicate any former names you may have used by writing them in the appropriate section.
  4. Proceed to Section 2. If you have been arrested or convicted of any relevant offenses, check the box affirming this statement.
  5. For each reportable offense, you must detail the offense, the date, and the location where the arrest or conviction occurred. Also include the docket number and the court name. Use additional paper if necessary.
  6. If you have no arrests or convictions to report, check the corresponding box in Section 3.
  7. In Section 4, ensure you sign your name confirming that all information provided is true and complete. Remember, false statements can lead to legal consequences.
  8. Lastly, include the date of signing the form right below your signature.

After completing the form, submit it to the appropriate administrator at your school or educational institution. Be sure to keep a copy for your records. It’s crucial to act quickly and accurately to avoid any issues related to employment compliance.

What You Should Know About This Form

What is the Act 24 PDE 6004 form?

The Act 24 PDE 6004 form is a standardized document used by the Pennsylvania Department of Education. It requires current and prospective employees of public and private schools, including intermediate units and vocational-technical schools, to report any arrests or convictions for specified offenses. This form ensures that schools comply with Act 24 of 2011 and Act 82 of 2012 and helps maintain safe educational environments.

Who needs to complete the PDE 6004 form?

Current and prospective employees of public and private schools, intermediate units, and area vocational-technical schools must complete the PDE 6004 form. This includes any individual applying for a job or who is already employed in these educational institutions.

What should I include in Section 2 of the form?

In Section 2, you must report any arrests or convictions for offenses specified in 24 P.S. §§1-111(e) or (f.1). This section requires details about each reportable offense, such as the type of offense, date and location of the incident, docket number, and the court involved. If you have no reportable offenses to disclose, you should proceed to Section 3.

What happens if I have no arrests or convictions to report?

If you have not been arrested or convicted of any reportable offenses, you should check the corresponding box in Section 3 of the form. This indicates that you are exempt from providing further information regarding arrests or convictions.

What are the penalties for providing false information on this form?

Providing false information on the PDE 6004 form can result in serious legal consequences. Individuals could face criminal prosecution under 18 Pa.C.S. §4904, which addresses unsworn falsification to authorities. It is crucial to ensure that all the information provided is truthful and accurate, as false statements can lead to significant penalties.

What types of offenses are considered reportable?

Reportable offenses include a range of serious crimes outlined in 24 P.S. §1-111(e) and (f.1). They encompass crimes like homicide, assault, sexual offenses, and certain drug-related offenses. Additionally, felonies and misdemeanors, depending on the degree and the time elapsed since the sentence, may also qualify as reportable.

Is there an exemption for current employees regarding this form?

Yes, current employees who completed a PDE-6004 form on or before December 27, 2011, and who have not been arrested or convicted of any reportable offenses since then are not required to complete an additional form. This is a provision meant to ease the burden on long-term employees who have already complied.

How should I submit the completed form?

After completing the PDE 6004 form, it must be submitted to the school administrator or the individual responsible for employment decisions within the school entity. If you are unsure about whom to send the form to, consult with your supervisor or contact the school administration office for guidance.

What is the time frame for reporting arrests or convictions?

Individuals must provide written notice of any arrests or convictions for reportable offenses within seventy-two (72) hours of the incident. Timely reporting is essential to comply with legal requirements and maintain transparency within the educational institution.

Common mistakes

Completing the Act 24 PDE-6004 form can be straightforward, but many individuals often make simple mistakes that can lead to issues. One common error is leaving sections blank. Every section of the form requires attention, whether it's personal information, reporting an arrest, or stating if there’s been no arrest. Omitting information creates a red flag, leading to delays or additional inquiries.

Another mistake people tend to make is using outdated names. When listing former names, ensure that all variations of your name are included, as this can affect background checks. Failing to report a former name can result in a mismatch between your identity and criminal records, complicating the process.

Incorrectly checking boxes is also frequent. The form requires individuals to specify if they are reporting an arrest or stating they have none. If someone mistakenly checks the wrong box, it may lead to serious repercussions. Make sure that the chosen option accurately reflects your situation.

Providing incomplete details about arrests or convictions can pose additional difficulties. It's essential to include all necessary information such as the offense, date, location, docket number, and court. Incomplete information may result in follow-up questions that delay processing.

Moreover, many individuals fail to sign the form. The certification section is crucial as it affirms the truthfulness of the information provided. A missing signature invalidates the submission altogether, leading to potential legal issues.

Another common mistake is submitting the form to the wrong person. The instructions clearly state who the form should be sent to. Sending it to an incorrect recipient can create confusion and further hinder the hiring process. Always confirm the correct submission person beforehand.

Failure to read the instructions thoroughly is another significant misstep. Each directive on the form holds importance. Ignoring these instructions can lead to oversights that cause problems later on.

Many applicants also neglect to check the submission date. The form states the timeline for reporting arrests or convictions must be adhered to. Delays can lead to questions about your integrity and potentially prevent employment opportunities.

Finally, submitting the form without reviewing it can lead to errors that may have been easily corrected. Take a moment to carefully read through everything before finalizing your submission. This final review can save time and trouble down the line.

Documents used along the form

The Act 24 PDE 6004 form is an essential document for reporting any arrests or convictions for specific offenses, particularly within educational environments in Pennsylvania. When completing this form, individuals might encounter various other documents that are commonly required to ensure compliance with legal standards for employment in schools or educational entities. Below are some key documents often used alongside the PDE 6004 form.

  • Act 151 Clearance: This is a background check that evaluates an individual's history regarding child abuse. It is mandatory for current and prospective school employees to demonstrate their ability to work safely with children.
  • FBI Criminal Background Check: Required for anyone who has resided outside of Pennsylvania in the last 10 years. This check involves a fingerprint-based report to uncover any criminal history at the federal level.
  • Act 34 Criminal History Check: This informs about the individual’s criminal history within Pennsylvania. It is essential for institutions to ensure that their employees have no significant criminal background.
  • Personal Statement: In some cases, individuals may be asked to provide a narrative or explanation of any past offenses reported on the PDE 6004. This statement aids in clarifying the context of the incidents.
  • Employee Verification Form: This document serves as a verification of current employment status in a school entity, confirming that the applicant is indeed applying for a position within the education system.
  • Join with Additional Documentation Form: Such a form allows applicants to attach any supplementary documents, which may provide more context about their legal history or any remedial actions taken since then.

Having a complete understanding of these documents can facilitate a smoother employment process in educational settings. Each document plays a crucial role in ensuring a safe environment for students and compliance with existing laws, ultimately benefiting both the employees and the institutions they serve.

Similar forms

The Act 24 PDE 6004 form is not unique in its purpose of reporting criminal history. Several other documents share similarities in function or requirements. Here’s a list of six such forms:

  • Criminal Records Check Form: This document often requires individuals to disclose any prior convictions or arrests. Like the PDE 6004, it is utilized for background checks in various employment sectors, particularly those involving vulnerable populations.
  • Employment Background Check Authorization: Similar to the PDE 6004, this form authorizes employers to conduct background checks, including criminal history, ensuring the safety of the workplace and clients alike.
  • Child Abuse Clearance Application: This application specifically requests information about previous child abuse allegations or findings. Like the PDE 6004, it aims to protect children in educational and caregiving environments.
  • Self-Disclosure Form: Often required during job applications, this form allows applicants to self-report any criminal history, similar to how the PDE 6004 functions during the hiring process for educational institutions.
  • Statement of Prior Criminal Activity: This document succinctly outlines any crimes committed by an applicant. It mirrors the PDE 6004 by requiring honesty and accuracy in reporting past offenses.
  • State Licensing Application: Many professional licensing bodies require a disclosure of any criminal history. This requirement is akin to the PDE 6004, as both serve to evaluate a person's fitness for specific roles.

Dos and Don'ts

When filling out the Act 24 PDE 6004 form, keep the following guidelines in mind:

  • Do provide accurate personal information. This includes your full legal name and any former names.
  • Do report all relevant arrests or convictions. If you have a reportable offense, list it clearly in the designated section.
  • Do check the appropriate boxes. Select the option that accurately reflects your situation regarding arrests or convictions.
  • Do sign and date the form. Ensure your certification is complete and correct to avoid legal consequences.
  • Do keep a copy for your records. Retaining a copy can be helpful for future reference.
  • Don't leave sections blank. Fill out all required fields to prevent delays in processing.
  • Don't provide false information. Misrepresentation can lead to severe legal penalties.
  • Don't forget to use legible handwriting. Ensure all information is easy to read, preferably in ink.
  • Don't submit the form late. Adhere to submission timelines to avoid penalties.
  • Don't ignore the instructions. Follow the guidance provided to ensure accuracy and compliance.

Misconceptions

Misconception 1: The Act 24 PDE 6004 form is only for new employees.

This form is required for both current and prospective employees of public and private schools, intermediate units, and area vocational-technical schools. Anyone in these roles must report relevant arrests or convictions, regardless of their employment status.

Misconception 2: It is acceptable to skip the form if I haven't been in trouble with the law.

If you have no reportable offenses, you must still complete the form by selecting the appropriate box in Section 3. This provides a clear record that you have not been arrested or convicted.

Misconception 3: Completing the form is optional.

Submission of this form is mandatory under Pennsylvania law. Failure to complete and submit the PDE 6004 can lead to significant consequences. All employees must comply with this requirement.

Misconception 4: The form does not have to be submitted soon after an arrest or conviction.

This form must be submitted within seventy-two (72) hours of any reportable arrest or conviction. Prompt reporting is essential to stay compliant with the law.

Misconception 5: I can provide incomplete information on the form.

All information provided needs to be complete and accurate. Falsifying or omitting details can result in criminal prosecution. It is vital to provide all necessary details legibly and correctly.

Key takeaways

The Act 24 PDE 6004 form is a critical document for individuals seeking employment within educational institutions in Pennsylvania. Here are key takeaways regarding the completion and use of this form:

  • Applicants must provide their full legal name and date of birth in Section 1.
  • Former names, if applicable, should also be disclosed in the same section.
  • Section 2 requires individuals to report any arrests or convictions that fall under specific categories defined by statutory law.
  • If no reportable offenses exist, individuals should check the box in Section 3, confirming the absence of such incidents.
  • Signing the form in Section 4 certifies the truthfulness of the provided information.
  • Falsifying information, including not reporting an arrest or conviction, can result in criminal prosecution.
  • Timing is essential; the form must be submitted within seventy-two (72) hours after any relevant incident.
  • Individuals are encouraged to clarify whom to submit the form to by contacting their employer or administration office.
  • The PDE-6004 form must be filled out legibly in ink to ensure clarity and prevent misunderstandings.