The Institute of Professional Educator Development
Telephone: (262)595-2180
Fax: (262)595-2265
CRIMINAL BACKGROUND CHECK FORM
(Must be submitted to and conducted by UW-Parkside University Police)
Complete all portions of this form and submit it to University Police along with the required fee of $20. Background checks may take up to two
days to prepare. Original results will be sent to The Institute of Professional Educator Development. You are also entitled to receive a copy of
the results from University Police.
The criminal background check is a screening method to protect children. It is also a duplication of questions you will be required to answer for
Wisconsin DPI teaching application and licensure processing. DPI will conduct a formal criminal background check on all licensure applicants
and will require finger handprints if you are from out of state or have worked out of state. For more information regarding this process, please
visit Form 1602-IS found at www.dpi.state.wi.us/dlsis/tel/applications.html.
Failure to complete this form will result in delay of admission or progression decisions. Please complete the following:
YOU ARE APPLYING FOR ADMISSION INTO:
Certification you are seeking:
ADMISSION TO THE EDUCATOR DEVELOPMENT PROGRAM OR
Middle Childhood - Early Adolescence 1 – 8
Student Name:
RESIDENCY
Early Adolescence - Adolescence 6-12
Date:
Yes
No
PR *
Yes
No
PR *
Yes
No
PR *
1. Have you ever been disciplined for alleged misconduct including but not limited to verbal, physical, or sexual abuse or
harassment in the course of any employment or as a member of any licensed or regulated profession?
2. Have you ever resigned, been disciplined or dismissed from any teaching or other school position, in part, for alleged
(check any which apply) □ immoral conduct or □ incompetence?
3. Have you ever had a certificate or license to teach or perform other school duties denied, revoked or suspended?
Yes
No
PR *
4. Is any investigation/discipline of your education related license or employment pending in any jurisdiction?
Yes
No
PR *
Yes
No
PR *
5. Have you ever been convicted of violating any civil, state, or federal law or local ordinance for actions involving sexual
conduct, physical abuse of a child, and/or contributing to the delinquency of a child?
6. Have you ever been convicted of any criminal offense (including criminal traffic matters, not general traffic violations)
Yes
No
PR *
in any jurisdiction? (check any which apply) □ felony or □ misdemeanor
7. Have you ever participated in a deferred prosecution agreement to resolve a criminal matter?
Yes
No
PR *
8. Are you currently on probation, parole, or other court-ordered supervision in any jurisdiction?
Yes
No
PR *
Yes
No
PR *
9. Have you ever been acquitted or found not guilty by reason of insanity, mental disease or defect, diminished mental
capacity or comparable legal defense or basis of an offense involving sexual conduct, or harm or threat of harm to another?
10. Is any investigation or criminal charge pending against you in any jurisdiction?
Yes
No
PR *
11. Have you (or a school district where you worked) ever been a party to a civil settlement, award, or agreement of any
kind that involved an allegation concerning your conduct as an educator or in an educationally related position or setting?
*If you have reported a “Yes” response on a previous application, check PR (previously reported) instead of Yes on this application if no further
conviction(s) has occurred.
“Immoral Conduct” means conduct or behavior that is contrary to commonly accepted moral or ethical standards and that endangers the
health, safety, welfare or education of any pupil. Sec 115.31(1)(c), Wis. Stats.
“Incompetence” means substantial, prolonged patterns of inadequate performance of duties or the lack of ability, legal qualifications or fitness
to discharge duties, affecting the health, welfare safety or education of pupils. PI 3.04(1)(b), Wis. Admin. Code.
IMPORTANT: You must respond to ALL questions.
For any “Yes” response to questions 1-11, attach an 8½” x 11” sheet with a written explanation. Submit certified copies of any criminal
complaint and relevant court documents pertinent to questions raised. If convicted, a copy of the criminal judgment must be included.
In the event that you are denied admission to the program based on the results of the criminal background check, you have the right to appeal
to the Educator Development Program Committee. For more information regarding the appeal procedure or any questions regarding the
criminal background check procedure, please call 262-595-2180.
All information on this form and documentation are true to the best of my knowledge. Any false statements or misleading statements may result in denial
to continue in the educator development program at UW-Parkside. I HEREBY AUTHORIZE any of my previous employers, law enforcement agencies, and
the courts to release, to the University of WI – Parkside, information which pertains to my responses to questions on this form.
Name (print or type)
Name of UWP University Police Official (print or type)
Signature (Sign in blue or black ink, in presence of university police official)
Signature UWP University Police Official
**Social Security #
Fee Paid
Date of Birth
**Collection of social security number is a requirement of s.118.19(1m) and (1r)l. The social security number be may be released to the Department of Justice, Department of Revenue,
and the Department of Workforce Development. Such information is made available to these governmental agencies for official purposes only.