Attachment 4
IRVINE Unified School District
Student Support Services Department
Supplemental Educational Services
Personnel Criminal Background, Tuberculosis Clearance,
Reporting OBLIGATIONS and Personnel Training Statement
I, Click here to enter text, am an authorized representative of Click here to enter text. I hereby declare under penalty of perjury under the laws of the State of California the following:
· Pursuant to Education Code Section 45125.1 of the California Education Code, the required criminal background check(s) of all persons [including staff, volunteers, and anyone who will be in contact (be it physical, verbal, or via online services) with program participants] who will be providing services to pupils in the Irvine Unified School District has been conducted and that none of these persons listed below have been reported by the California Department of Justice (CDOJ), if applicable, OR their home state Department of Justice or equivalent agency, if they do not reside in California, AND the Federal Bureau of Investigation (FBI) as having been convicted of a serious or violent felony as specified in Penal Code Section 667.5(c) and/or 1192.7(c). Tutors who do not live in the United States and whose criminal records are not available to the FBI through their home countries, cannot be cleared to work with IUSD students.
· The below named individuals have been cleared by medical personnel within the last four (4) years as being free of active Tuberculosis (TB) pursuant to Education Code section 49406. (Tutors only providing services via phone or internet do not need this clearance.)
· The persons listed below agree to adhere to the child and dependent adult abuse reporting obligations and procedures as specified in the California Penal Code section 11166, and to the requirements for reporting missing children as specified in the California Education Code section 49370.
· The persons listed below agree that SES individual sessions (1 to 1) will only be conducted if an adult (21 years or older) known to the family is present at the SES location the entire time that the PROVIDER, its employees and/or volunteers and substitutes are with the student.
· Pursuant to Irvine Unified School District (IUSD), No Child Left Behind Supplemental Educational Services Master Contract, Section IV: Personnel and Section V: Health and Safety the required professional development/training of all persons who will be providing services to the Irvine Unified School District has been conducted.
The persons listed below are currently employees or volunteers of PROVIDER and are currently active employees of a public school district who have submitted to and received a fingerprint clearance by the CDOJ and FBI and have been trained in using the specific program and curriculum utilized by PROVIDER and in Child Abuse and Missing Children reporting procedures:Employee’s/Volunteer’s
Full Name & Title / FBI / CDOJ / TB / School District / Credential
The persons listed below are currently not active employees of a public school district, not public school employees and/or volunteers and are employees or volunteers of PROVIDER who have submitted to and received a fingerprint clearance by the CDOJ and FBI and have been trained in using the specific program and curriculum utilized by PROVIDER and in Child Abuse and Missing Children reporting procedures:
Employee’s/Volunteer’s Full Name & Title / FBI / CDOJ / TB / School Level Attended/Major/Degree:
The persons listed below are currently not credentialed public school employees or/are Independent Contractors who have submitted to and received a fingerprint clearance by the CDOJ and FBI and have been trained to tutor using the specific program and curriculum utilized by CONTRACTOR and in Child Abuse and Missing Children reporting procedures:
Independent Contractor
paid under IRS 1099 Rules
Full Name & Title / FBI / CDOJ / TB / School Level Attended/Major/Degree:
The persons listed below are currently our employees or volunteers (and may or may not include current school district credentialed or non-credentialed staff) residing in a different state (not California) in the United States and have submitted to and received a fingerprint clearance through their state of residence equivalent to the CDOJ and the organization I am representing above is receiving their annual FBI criminal records histories. These employees/volunteers have been trained using the specific program and curriculum utilized by PROVIDER and in Child Abuse and Missing Children reporting procedures:
Employee’s/Volunteer’s
Full Name & Title / FBI / CDOJ / TB / School District/Credential/
School Level Attended/Major/Degree:
I agree to keep this list current and to submit an addendum with each monthly invoice if/when changes occurs and/or additional personnel are added or personnel are removed. I understand that if, at any time, I use a substitute for any personnel on the list, the stipulations hold true for them as well. I further agree to prepare a new Personnel Clearance Statement, at a minimum, on an annual basis.
Executed on / , at / ,Date / City / State
Signature / Name (PRINT) / Title