Sherese Cobbs

Home health care

• Hiring Entity's Name: Chicago Public Schools
• Contact Person: Jerry Taylor
• Address: 42 West Madison Street
• City, State, ZIP: Chicago, IL 60602
• Telephone Number: 773-553-4748
• Email: faithslaw@cps.edu
• Sent to Current/Former Employer By (insert name): CPS On (insert date):
• Received at Hiring Entity: By (insert name): On (insert date):

• Name: (First, Middle, Last):
• Any former names by which the Applicant has been identified:
• Date of Birth:
• Last Four Digits of Social Security Number:
• IEIN (if applicable):
• Email:
• Street Address:
• City, State, ZIP:

• Employer:
• Contact Person:
• Address:
• City, State, ZIP
• Telephone Number:
• Email:
• Position Held:
• Approximate Dates of Employment:

• By signing this form, I do hereby authorize my current/former employer identified in Section 3, above, to disclose to the hiring entity identified in Section 1, above, the following information and any records related to that information:
• 1. The dates of my current/former employment;
• 2. A statement as to whether I have ever been the subject of an allegation of 'sexual misconduct,' as defined in 105 ILCS 5/22-85.5 (Sexual Misconduct), (unless a subsequent investigation resulted in a finding that the allegation was false, unfounded, or unsubstantiated);
• 3. A statement as to whether I have ever been discharged from, been asked to resign from, resigned from, or otherwise been separated from any employment; been disciplined by the employer; or had an employment contract not renewed due to an adjudication or finding of Sexual Misconduct, or while an allegation of Sexual Misconduct against me was pending or under investigation (unless a subsequent investigation resulted in a finding that the allegation was false, unfounded, or unsubstantiated);
• 4. A statement as to whether I have ever had a license or certificate suspended, surrendered, or revoked; or had an application for licensure, approval, or endorsement denied due to an adjudication or finding of Sexual Misconduct or while an allegation of Sexual Misconduct against me was pending or under investigation (unless a subsequent investigation resulted in a finding that the allegation was false, unfounded, or unsubstantiated); and
• 5. Any other pertinent records, documentation, or information related to items 2 through 4 above.
• Further, by signing this form, I do hereby release my current/former employer identified in Section 3, above, from any criminal or civil liability that may arise from the disclosure of information and records authorized under this Section 4 to the extent such release is permitted by law.
• Applicant Signature Printed Name Date

• This form must be completed and returned to the hiring entity listed in Section 1 within 20 days of receipt.
• Position held by Applicant: Dates of Employment:
• Person Completing Form: Title:
• Telephone Number: Email:
• For purposes of the following requests, the term 'sexual misconduct,' as defined in 105 ILCS 5/22-85.5 (Sexual Misconduct), means any act, including, but not limited to, any verbal, nonverbal, written, or electronic communication or physical activity, that:
• 1. Applicant committed as an employee or agent of a school district, charter school, or nonpublic school during which time Applicant engaged in or had the possibility of engaging in the care, supervision, guidance, control of or routine interaction with students; and
• 2. Was directed toward or with a student to establish a romantic or sexual relationship with the student. Such an act includes, but is not limited to, any of the following:
• A. A sexual or romantic invitation;
• B. Dating or soliciting a date;
• C. Engaging in sexualized or romantic dialog;
• D. Making sexually suggestive comments that were directed toward or with a student;
• E. Self-disclosure or physical exposure of a sexual, romantic, or erotic nature; and
• F. A sexual, indecent, romantic, or erotic contact with the student.

• 1. To the best of your knowledge, has Applicant ever been the subject of an allegation of Sexual Misconduct? Check no if a subsequent investigation resulted in a finding that the allegation was false, unfounded, or unsubstantiated.
• [ ] Yes
• [ ] No or [ ] I have no records or other evidence pertaining to this question. I have no knowledge of information pertaining to the Applicant that would disqualify Applicant from employment.
• 2. To the best of your knowledge, has Applicant ever been discharged from, been asked to resign from, resigned from, or otherwise been separated from any employment; been disciplined by you (the employer); or had an employment contract not renewed due to an adjudication or finding of Sexual Misconduct, or while an allegation of Sexual Misconduct against Applicant was pending or under investigation? Check no if a subsequent investigation resulted in a finding that the allegation was false, unfounded, or unsubstantiated.
• 3. To the best of your knowledge, has Applicant ever had a license or certificate suspended, surrendered, or revoked; or had an application for licensure, approval, or endorsement denied due to an adjudication or finding of Sexual Misconduct or while an allegation of Sexual Misconduct against Applicant was pending or under investigation? Check no if a subsequent investigation resulted in a finding that the allegation was false, unfounded, or unsubstantiated.
• If your answer to any of the above questions is 'yes', you must provide any records and information in your control or possession related to the affirmative response. Please provide the information in the space below and attach any responsive records to this form. Additional pages of information may be attached.
• I have read and understand the contents of this form. I certify that, to the best of my knowledge, the responses provided above are accurate, and the records provided in connection with these responses are true and correct.
• Current/Former Employer Signature Printed Name/Title Date