FLORIDA DEPARTMENT OF EDUCATION

  

 

  

  

  

  

  

DAVID C. ASHBURN

CHARLIE CRIST

  

  

  

  

  

DIRECTOR

 

Commissioner

  

  

  

  

  

DIVISION OF PROFESSIONAL EDUCATORS

 

 

 

 

  

  

  

  

  

  

  

Contact Person

 

  

  

  

  

  

  

Name:

Marian Lambeth

August

28,

2002

     

Phone:

850/488-2481

 

  

  

  

  

  

  

Suncom:

278-2481

 

  

  

  

  

  

  

E-mail:

Marian.Lambeth@fldoe.org

  

  

  

  

  

  

  

DPE :

03-04

 

MEMORANDUM

 

TO:

District School Superintendents

Personnel

Directors

Certification

Directors

 

FROM:

David C. Ashburn

 

SUBJECT:

Educator Misconduct – District Reporting Form

 

 

Attached is a copy of the District Reporting Form that is required to accompany District

investigations that are being forwarded to the Office of Professional Practices for review.

 

Please complete the Form in its entirety and attach the District’s investigative report, along with

all of the documents noted in Items 1, 2, and 3. The Office of Professional Practices Services

will also require a description of the specific position held by the educator at the time of the

allegation and a definitive description of the allegation(s).

 

If you have questions or need clarification, please do not hesitate to contact Ms. Lambeth at the

number listed above.

 

Thank you for your cooperation.

 

DCA/mll

 

Attachment

 

325 West Gaines Street

i

Room 203

i

Tallahassee, Florida 32399-0400

i

(850) 487-3663

i

FAX (850) 488-3352

http:/www.firn.edu/doe

 

An affirmative action/equal opportunity employer

 

---

DATE:________________

 

DISTRICT REPORTING FORM

 

 

1.

 

DISTRICT:_______________ (a) CONTACT PERSON:________________________ (b) PHONE:________________

 

 

2.

 

RESPONDENT’S NAME: _________________________ (a) ADDRESS:____________________________________

 

=========================================================================================

 

(b) RESPONDENT’S Phone: (HOME)_____________ (WORK)_____________ (c) DATE OF BIRTH:_______________

 

 

(d) SSN: _____________________ (e) DOE CERTIFICATE #: ____________ (f) YEARS OF EXPERIENCE: _______

 

 

(g) SCHOOL: _________________________________________________________________________________________

 

 

(h) POSITION: _________________________________ (i) SUBJECT/GRADE LEVEL: ___________________________

 

 

******************************************************************************************************

 

CONTRACT

  

STATUS

CURRENT

EMPLOYMENT

STATUS

ANNUAL

_______

STUDENT CONTACT _____

RESIGNED

_____

CONTINUING

_______

SUSPENDED WITH PAY

_____

TERMINATED

______

PROF. SER.

_______

SUSPENDED WITHOUT PAY

_____

NONRENEWED

______

SUBSTITUTE

_______

TEMPORARY DUTY

_____

REASSIGNED TO

______

 

 

ALLEGATION:________________________________________________________________________________________

 

 

 

______________________________________________________________________________________________________

 

 

 

 

******************************************************************************************************

 

ENCLOSE THE FOLLOWING REQUIRED DOCUMENTATION:

 

1.

 

All District Investigative Materials (i.e. notarized statements, arrest report(s), court documents, newspaper articles, local

investigative reports, termination documents, letter of resignation, district disciplinary action documents(s).

 

2.

 

Copy of the Respondent’s Florida Educator’s Certificate, and Most Recent Application for a Florida Educator’s Certificate.

 

3.

 

Name, Address, Telephone Numbers, Date of Birth, and School NOW attending of ALL VICTIMS and WITNESSES, if not

already included in the District Investigative Materials (complete page two if necessary).

 

325 West Gaines Street

i

Room 203

i

Tallahassee, Florida 32399-0400

i

(850) 487-3663

i

FAX (850) 488-3352

http:/www.firn.edu/doe

 

An affirmative action/equal opportunity employer

 

---

325 West Gaines Street

i

Room 203

i

Tallahassee, Florida 32399-0400

i

(850) 487-3663

i

FAX (850) 488-3352

http:/www.firn.edu/doe

 

An affirmative action/equal opportunity employer

 

DISTRICT REPORTING FORM

PAGE TWO

 

VICTIMS

 

 

NAME:__________________________________________ NAME:__________________________________________

 

ADDRESS:_______________________________________ ADDRESS:_______________________________________

 

_________________________________________________ _________________________________________________

 

TELEPHONE #:___________________________________ TELEPHONE #:___________________________________

 

D.O.B.:__________________________________________ D.O.B.:__________________________________________

 

PRESENT SCHOOL:______________________________ PRESENT SCHOOL:______________________________

 

******************************************************************************************************

 

WITNESSES

 

 

NAME:__________________________________________ NAME:__________________________________________

 

ADDRESS:_______________________________________ ADDRESS:_______________________________________

 

_________________________________________________ _________________________________________________

 

TELEPHONE #:___________________________________ TELEPHONE #:___________________________________

 

D.O.B.:__________________________________________ D.O.B.:__________________________________________

 

PRESENT SCHOOL:______________________________ PRESENT SCHOOL:______________________________

 

******************************************************************************************************

 

WITNESSES

 

 

NAME:__________________________________________ NAME:__________________________________________

 

ADDRESS:_______________________________________ ADDRESS:_______________________________________

 

_________________________________________________ _________________________________________________

 

TELEPHONE #:___________________________________ TELEPHONE #:___________________________________

 

D.O.B.:__________________________________________ D.O.B.:__________________________________________

 

PRESENT SCHOOL:______________________________ PRESENT SCHOOL:______________________________

 

 

 

REV. 8/96