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The Act 24 PDE 6004 form plays a crucial role in ensuring the safety and integrity of educational environments in Pennsylvania. Designed for current and prospective employees of public and private schools, this form serves as a means for individuals to disclose any arrests or convictions related to specific offenses. It consists of several sections, starting with personal information, where individuals provide their full legal name, date of birth, and any former names. The second section prompts users to report any relevant arrests or convictions, requiring details such as the nature of the offense, date, location, and court involved. Alternatively, if there are no reportable offenses, individuals can indicate this in Section 3. The form also emphasizes the importance of accuracy and honesty, as individuals must certify the truthfulness of their statements under penalty of law. It is essential for employees to complete and submit this form to the appropriate school administration, ensuring compliance with Pennsylvania law. Understanding the requirements and implications of the PDE 6004 form is vital for maintaining a safe educational atmosphere for all students and staff.

Preview - Act 24 Pde 6004 Form

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PDE-6004 (8/28/2012)
ARREST/CONVICTION REPORT AND CERTIFICATION FORM
(under Act 24 of 2011 and Act 82 of 2012)
Section 1. Personal Information
Full Legal Name:
Any former names
by which you have
been identified:
Date of Birth: _____/_____/________
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
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PDE-6004 (8/28/2012)
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.
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PDE-6004 (8/28/2012)
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)
(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.
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)

Document Specifics

Fact Name Details
Governing Laws The PDE-6004 form is governed by Act 24 of 2011 and Act 82 of 2012, specifically under 24 P.S. §1-111.
Purpose This form is designed for current and prospective employees of public and private schools to report any arrests or convictions for specific offenses.
Submission Requirement All current and prospective employees must complete and submit the form to the appropriate school administrator.
Reporting Timeline Employees are required to report any arrest or conviction within seventy-two (72) hours.
Certification By signing the form, individuals certify that the information provided is true, correct, and complete, under penalty of law.
Exemption Clause Employees who completed a PDE-6004 before December 27, 2011, and have no new reportable offenses are exempt from submitting another form.

Act 24 Pde 6004: Usage Instruction

Completing the Act 24 PDE 6004 form is an important step for current and prospective employees of educational institutions in Pennsylvania. This process ensures that all necessary information is accurately reported. Follow the steps below to fill out the form correctly.

  1. Begin with Section 1: Personal Information. Fill in your full legal name and date of birth. If you have any former names, include them as well.
  2. Move to Section 2: Report of Arrest or Conviction. If you have been arrested for or convicted of any reportable offenses, check the appropriate box. If you do not have any offenses to report, skip to Section 3.
  3. In Section 2, provide details for each arrest or conviction. Include the offense, date and location of the arrest or conviction, the docket number, and the applicable court. If you need more space, attach additional sheets as necessary.
  4. If you have not been arrested or convicted of any reportable offenses, check the box in Section 3 to confirm this.
  5. Proceed to Section 4: Certification. Sign and date the form to certify that the information provided is true, correct, and complete.
  6. Review the completed form for accuracy and legibility. Ensure that all sections are filled out as required.
  7. Submit the form to the appropriate administrator or person responsible for employment decisions at your school entity.

After submitting the form, it will be reviewed by the relevant authorities. Make sure to keep a copy for your records. If you have any questions about the process, reach out to your supervisor or the administration office for guidance.

Learn More on Act 24 Pde 6004

What is the Act 24 PDE 6004 form?

The Act 24 PDE 6004 form is a standardized document used in Pennsylvania. It is designed for current and prospective employees of public and private schools, as well as vocational-technical schools. This form allows individuals to report any arrests or convictions for specific offenses that are outlined in Pennsylvania law.

Who needs to complete the PDE 6004 form?

All current and prospective employees of public and private schools, intermediate units, and area vocational-technical schools must complete this form. This includes teachers, administrators, and support staff. If you have been arrested or convicted of a reportable offense, you are required to fill out this form.

What are reportable offenses?

Reportable offenses include serious crimes such as:

  • Criminal homicide
  • Aggravated assault
  • Stalking
  • Kidnapping
  • Rape
  • Sexual assault
  • Corruption of minors

For a complete list, refer to the instructions on the form or the relevant Pennsylvania statutes.

What should I do if I have no arrests or convictions to report?

If you have not been arrested or convicted of any reportable offenses, simply check the box in Section 3 of the form. You can then proceed to complete the certification section.

What happens if I provide false information on the form?

Providing false information on the PDE 6004 form can lead to serious consequences. You may face criminal prosecution for unsworn falsification to authorities. It is crucial to ensure that all information reported is accurate and complete.

How long do I have to submit the form after an arrest or conviction?

You must submit the PDE 6004 form within seventy-two (72) hours of any arrest or conviction for a reportable offense. Timely reporting is essential to comply with Pennsylvania law.

Where should I send the completed form?

The completed form should be submitted to the administrator or the person responsible for employment decisions in your school entity. If you are unsure about where to send it, contact your supervisor or the school administration office for guidance.

Is there an exemption for employees who completed the form previously?

Yes, if you completed a PDE 6004 form on or before December 27, 2011, and have not been arrested or convicted of a reportable offense since then, you are not required to complete an additional form. However, if there have been any changes in your status, you must report them accordingly.

Common mistakes

Filling out the Act 24 PDE 6004 form is an important step for current and prospective employees in Pennsylvania’s educational institutions. However, many individuals make common mistakes that can lead to complications. Here are seven frequent errors to avoid.

One of the most significant mistakes is failing to provide complete personal information. The form requires your full legal name, date of birth, and any former names. Omitting any of this information can delay processing or even result in rejection of your application. Always double-check that these details are accurate and legible.

Another common error is misunderstanding the section regarding arrests or convictions. Some people mistakenly believe they do not need to report certain offenses. However, if you have been arrested or convicted of any offense listed under 24 P.S. §§1-111(e) or (f.1), you must disclose it. Ignoring this requirement can lead to serious consequences, including potential criminal prosecution for falsification.

In addition, individuals often neglect to provide specific details about their arrests or convictions. The form asks for the date, location, docket number, and applicable court for each reportable offense. Providing vague or incomplete information can raise red flags and complicate your application process. It's essential to be thorough in this section.

Another frequent mistake involves checking the wrong box in Section 2 or Section 3. If you have a reportable offense, make sure to check the appropriate box indicating that you are reporting it. Conversely, if you have no reportable offenses, ensure you check the box stating that you have not been arrested or convicted. Misleading answers can have serious repercussions.

Many people also forget to sign and date the certification section of the form. This step is crucial, as your signature confirms that the information provided is true and complete. Without a signature, the form may be considered invalid. Always remember to review the entire form before submission.

Additionally, individuals sometimes fail to submit the form to the correct person or department. It’s essential to know who is responsible for handling these forms within your school entity. If you’re unsure, reach out to your supervisor or the administration office for guidance. Sending the form to the wrong person can delay your application.

Lastly, some applicants overlook the importance of timeliness. The form must be submitted within seventy-two hours after an arrest or conviction for a reportable offense. Delays can lead to complications in your employment status. Always be mindful of the deadlines associated with this process.

By avoiding these common mistakes, you can ensure a smoother experience when completing the Act 24 PDE 6004 form. Taking the time to carefully fill out the form and double-check your information will help you navigate this important requirement more effectively.

Documents used along the form

When completing the Act 24 PDE 6004 form, there are several other documents that may be required to provide additional context or information. Each of these forms serves a specific purpose in the process of reporting arrests or convictions, ensuring that all necessary information is accurately conveyed.

  • Background Check Authorization Form: This form allows the school or organization to conduct a background check on the individual. It typically requires the individual to provide consent for the release of their criminal history and other relevant information.
  • Criminal History Record Check: This document is obtained from law enforcement agencies and provides a detailed account of any criminal history. It is often required to verify the information reported on the PDE 6004 form.
  • Personal Statement: A personal statement may be requested to give the individual an opportunity to explain the circumstances surrounding any reported arrests or convictions. This can help provide context to the reviewing authority.
  • Employment Application: Along with the PDE 6004 form, an employment application may be required. This document typically includes personal information, work history, and references, allowing for a comprehensive view of the applicant.
  • Release of Information Form: This form grants permission for the school or organization to obtain information from other sources, such as previous employers or educational institutions, to verify the applicant’s background.
  • Affidavit of Good Moral Character: In some cases, individuals may be asked to provide an affidavit affirming their good moral character. This document can support their application by attesting to their integrity and reliability.
  • Letters of Recommendation: Letters from previous employers or community members can bolster an application. These letters serve as endorsements of the individual's character and work ethic.
  • Documentation of Rehabilitation: For those with past convictions, providing proof of rehabilitation, such as completion of a program or community service, can be beneficial in demonstrating personal growth and change.

Gathering these documents alongside the Act 24 PDE 6004 form can facilitate a smoother review process and help present a complete picture to the hiring authority. Being thorough and transparent is key to ensuring that all necessary information is provided.

Similar forms

The Act 24 PDE 6004 form shares similarities with the Criminal Background Check form. Both documents require individuals to disclose any arrests or convictions related to specific offenses. They serve the purpose of ensuring that employers, particularly in sensitive positions such as education, have access to relevant criminal history. The Criminal Background Check form typically includes sections for personal identification and details of any reported offenses, much like the PDE 6004. Both forms aim to promote safety and accountability within organizations that work with vulnerable populations.

Another document similar to the Act 24 PDE 6004 is the Employment Application form. This form often requires applicants to answer questions regarding their criminal history as part of the hiring process. Like the PDE 6004, the Employment Application seeks to gather information that can help employers make informed decisions about potential hires. The key difference lies in the scope; while the Employment Application may focus on various qualifications, the PDE 6004 specifically targets reportable offenses under Pennsylvania law.

The Child Abuse History Clearance form also parallels the Act 24 PDE 6004. This document is crucial for individuals seeking employment in child-related fields. It requires the applicant to provide information about any history of child abuse, similar to how the PDE 6004 requires disclosure of arrests and convictions. Both forms are designed to protect children by ensuring that individuals with troubling backgrounds are not placed in positions of trust.

The FBI Criminal Background Check form is another document akin to the PDE 6004. This form is often required for individuals applying for jobs in education and other sensitive sectors. Both forms necessitate a thorough examination of an individual's criminal history. However, the FBI form provides a broader scope, including federal offenses, while the PDE 6004 focuses specifically on Pennsylvania state law violations.

The State Police Criminal Record Check form is similar as well, as it also aims to verify an individual's criminal history. Like the PDE 6004, it requires detailed personal information and specifics about any arrests or convictions. The State Police form is often used in conjunction with the PDE 6004 to provide a comprehensive view of an applicant's background, ensuring that organizations can adequately assess the risk associated with hiring a particular individual.

The Professional License Application form often includes questions about an applicant's criminal history, making it similar to the PDE 6004. Both documents are crucial in ensuring that individuals in licensed professions meet ethical and legal standards. The Professional License Application typically requires disclosures relevant to maintaining the integrity of the profession, paralleling the PDE 6004's focus on safeguarding vulnerable populations.

The Self-Disclosure Form for Employment is another document that aligns closely with the Act 24 PDE 6004. This form typically asks applicants to disclose any criminal history as part of the hiring process. Like the PDE 6004, it emphasizes transparency and accountability, allowing employers to make informed decisions based on an applicant’s background. The key distinction is that the Self-Disclosure Form may not be limited to specific offenses, while the PDE 6004 is strictly focused on reportable offenses under Pennsylvania law.

Lastly, the Certificate of Good Conduct form can be compared to the PDE 6004. This document is often used by individuals seeking to demonstrate their rehabilitation after a criminal conviction. While the PDE 6004 requires disclosure of any arrests or convictions, the Certificate of Good Conduct serves as evidence of an individual's efforts to reintegrate into society. Both forms ultimately aim to provide a clearer picture of an individual's history, but they serve different purposes in the context of employment and background checks.

Dos and Don'ts

When filling out the Act 24 PDE 6004 form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are nine things you should and shouldn't do:

  • Do provide your full legal name as it appears on official documents.
  • Don't leave any sections blank; every part of the form must be filled out.
  • Do include any former names you have used, if applicable.
  • Don't forget to check the box indicating whether you have been arrested or convicted of a reportable offense.
  • Do specify details of any arrests or convictions, including the date and location.
  • Don't provide false information; this can lead to serious legal consequences.
  • Do sign and date the form to certify that the information is true and complete.
  • Don't submit the form without reviewing it for accuracy.
  • Do submit the completed form to the appropriate school administrator or employment decision-maker.

By following these guidelines, you can help ensure that your form is processed smoothly and without issues.

Misconceptions

Understanding the Act 24 PDE 6004 form is essential for current and prospective employees in Pennsylvania's educational institutions. However, several misconceptions often arise regarding this form. Here are seven common myths, along with clarifications to help demystify the process.

  • Myth 1: The form is only for new employees.
  • This is not true. Current employees must also complete the form if they have been arrested or convicted of a reportable offense.

  • Myth 2: Only serious crimes need to be reported.
  • Many people believe that only felonies need to be disclosed. However, the form requires reporting any offenses listed under 24 P.S. §§1-111(e) or (f.1), which may include misdemeanors as well.

  • Myth 3: You can skip the form if you haven't been arrested recently.
  • Even if you haven't been arrested in the past ten years, you are still required to submit the form if you have a history of reportable offenses.

  • Myth 4: The information is not confidential.
  • Many assume that the details on this form are public. In reality, the information is kept confidential and is only shared with authorized personnel involved in employment decisions.

  • Myth 5: You can provide incomplete information without consequences.
  • This misconception can lead to serious repercussions. Failing to provide complete and accurate information can result in criminal prosecution under 18 Pa.C.S. §4904.

  • Myth 6: You don't need to report arrests that didn't lead to convictions.
  • It's important to note that any arrest for a reportable offense must be disclosed, regardless of whether it resulted in a conviction.

  • Myth 7: Completing the form is optional.
  • Completing the PDE 6004 form is mandatory for all employees of public and private schools, as it is a legal requirement under Pennsylvania law.

By dispelling these misconceptions, individuals can better understand their responsibilities and the importance of transparency in the educational environment. Properly completing the PDE 6004 form is crucial for maintaining a safe and compliant workplace.

Key takeaways

The Act 24 PDE 6004 form serves a specific purpose in reporting arrests or convictions for certain offenses. Understanding how to accurately fill out and utilize this form is essential for compliance.

  • The form must be completed by current and prospective employees of public and private schools, intermediate units, and area vocational-technical schools.
  • Personal information, including full legal name and date of birth, must be accurately provided in Section 1.
  • Section 2 requires individuals to report any arrests or convictions for offenses listed under 24 P.S. §§1-111(e) or (f.1).
  • If there are no reportable offenses, individuals should check the box in Section 3 to indicate this status.
  • Certification in Section 4 is mandatory, confirming that all provided information is true and complete.
  • False statements may lead to criminal prosecution under Pennsylvania law.
  • Individuals must submit the completed form to the appropriate administrator responsible for employment decisions.
  • It is required to complete and submit the form within seventy-two hours of any arrest or conviction.
  • Current employees who completed a PDE-6004 prior to December 27, 2011, and have no new offenses are exempt from filling out a new form.

Adhering to these guidelines ensures compliance with the reporting requirements set forth by the Pennsylvania Department of Education.