"Employment History Verification Form" - Nevada

Employment History Verification Form is a legal document that was released by the Nevada Department of Education - a government authority operating within Nevada.

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Las Vegas Office
Carson City Office
9890 South Maryland Parkway
700 East Fifth Street
Suite 221
Carson City, Nevada 89701
Las Vegas, Nevada 89183
775-687-9115
702-486-6458
State of Nevada
Department of Education
Employment History Verification Form
(Please Print Clearly)
To:
Name of Current/Former Employer: _____________________________________________________
Address: ___________________________________________________________________________
Contact Person/Title: _________________________________________________________________
The applicant named below is under consideration for employment with ________________________
and has indicated that he/she is/was employed by your entity. Pursuant to Chapters 391 and 394 of
Nevada Revised Statutes, as amended by the Assembly Bill 362 during the 2017 Legislative Session, we
request that you provide the following information regarding his/her employment with you.
Name of Applicant: ___________________________________________________________________
Other Name Used (if any): _____________________________________________________________
Date of Birth: ___________________________
SSN Last 4 Digits: ______________________
Pursuant to Chapter 391 of Nevada Revised Statutes, as amended by Assembly Bill 362 during the 2017 Legislative
Session:
“Sexual misconduct” means any act, including, without limitation, any verbal, nonverbal, written or
electronic communication or physical activity, directed toward or with a child, regardless of the age of the
child, that is designed to establish a romantic or sexual relationship with the child.
“Sexual offense” has the meaning ascribed to it in NRS 179D.097.
Except as otherwise provided in a, b, or c below, the Nevada Department of Education, a local educational
agency or an employee, contractor or agent thereof who works at a public school shall not assist an
employee, contractor or agent who works at a school to obtain new employment, apart from the routine
transmission of administrative and personnel files, if the person or entity has actual or constructive
knowledge that such an employee, contractor or agent has engaged in sexual misconduct regarding a
minor or pupil. The provisions of this subsection do not apply if:
The information giving rise to actual or constructive knowledge has been properly reported to a
law enforcement agency with jurisdiction over the alleged misconduct and any other authorities
required by federal, state or local law, including, without limitation, Title IX of the Education
Amendments Act of 1972, 20 U.S.C. §§ 1681 et seq., and any regulations adopted pursuant
thereto, and the matter has been officially closed, or the District Attorney or law enforcement
agency with jurisdiction over the alleged misconduct has investigated the allegations and notified
school officials that there is insufficient information to establish that the employee, contractor or
agent engaged in sexual misconduct regarding a minor or pupil;
The employee, contractor or agent has been charged with and acquitted or otherwise exonerated
of the alleged misconduct; or
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Las Vegas Office
Carson City Office
9890 South Maryland Parkway
700 East Fifth Street
Suite 221
Carson City, Nevada 89701
Las Vegas, Nevada 89183
775-687-9115
702-486-6458
State of Nevada
Department of Education
Employment History Verification Form
(Please Print Clearly)
To:
Name of Current/Former Employer: _____________________________________________________
Address: ___________________________________________________________________________
Contact Person/Title: _________________________________________________________________
The applicant named below is under consideration for employment with ________________________
and has indicated that he/she is/was employed by your entity. Pursuant to Chapters 391 and 394 of
Nevada Revised Statutes, as amended by the Assembly Bill 362 during the 2017 Legislative Session, we
request that you provide the following information regarding his/her employment with you.
Name of Applicant: ___________________________________________________________________
Other Name Used (if any): _____________________________________________________________
Date of Birth: ___________________________
SSN Last 4 Digits: ______________________
Pursuant to Chapter 391 of Nevada Revised Statutes, as amended by Assembly Bill 362 during the 2017 Legislative
Session:
“Sexual misconduct” means any act, including, without limitation, any verbal, nonverbal, written or
electronic communication or physical activity, directed toward or with a child, regardless of the age of the
child, that is designed to establish a romantic or sexual relationship with the child.
“Sexual offense” has the meaning ascribed to it in NRS 179D.097.
Except as otherwise provided in a, b, or c below, the Nevada Department of Education, a local educational
agency or an employee, contractor or agent thereof who works at a public school shall not assist an
employee, contractor or agent who works at a school to obtain new employment, apart from the routine
transmission of administrative and personnel files, if the person or entity has actual or constructive
knowledge that such an employee, contractor or agent has engaged in sexual misconduct regarding a
minor or pupil. The provisions of this subsection do not apply if:
The information giving rise to actual or constructive knowledge has been properly reported to a
law enforcement agency with jurisdiction over the alleged misconduct and any other authorities
required by federal, state or local law, including, without limitation, Title IX of the Education
Amendments Act of 1972, 20 U.S.C. §§ 1681 et seq., and any regulations adopted pursuant
thereto, and the matter has been officially closed, or the District Attorney or law enforcement
agency with jurisdiction over the alleged misconduct has investigated the allegations and notified
school officials that there is insufficient information to establish that the employee, contractor or
agent engaged in sexual misconduct regarding a minor or pupil;
The employee, contractor or agent has been charged with and acquitted or otherwise exonerated
of the alleged misconduct; or
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The case or investigation remains open and there have been no charges filed against, or
indictment of, the employee, contractor or agent within 4 years after the date on which the
information was reported to a law enforcement agency.
A local educational agency or a public school shall not enter into any agreement with a person convicted
of a sexual offense involving a minor to keep the conviction or the circumstances surrounding the offense
confidential.
1. Please indicate the dates the applicant was employed with your entity:
From _______________ to _______________
2. Has the applicant named above:
Yes ____ No ____ Been the subject of an investigation concerning an alleged sexual offense
conducted by your entity? (An employer or former employer is not required to provide this
information if, after investigating the alleged violation, the employer determined that the
allegations were false, unfounded, unsubstantiated, or inconclusive.)
Yes ____ No ____Been discharged or disciplined, had a contract not renewed, been asked to
resign from employment, or resigned or otherwise separated from employment while an
investigation concerning an alleged sexual offense was pending, or upon conclusion of such an
investigation where the applicant was found to have committed the sexual offense?
Yes ____ No ____ Had a license or certificate suspended or revoked, or been required to
surrender a license or certificate, while an investigation concerning an alleged sexual offense
was pending, or upon conclusion of such an investigation where the applicant was found to have
committed the sexual offense?
I certify that the information above is true and correct to the best of my knowledge.
Signature _________________________________________ Date _________________________
Printed Name ______________________________________ Title _________________________
Contact Phone Number _____________________________ Email _________________________
Section 9 of Assembly Bill 362 during the 2017 Legislative Session provides that an employer or former employer
contacted by a board of trustees of a school district, governing body of a charter school, governing body of a
private school, governing body of a university school for profoundly gifted pupils or independent contractor
pursuant to Chapters 391 and 394 of Nevada Revised Statutes:
Shall provide the information requested not later than 20 days after the date on which the board of
trustees, governing body or independent contractor contacts the employer or former employer.
Is immune from civil and criminal liability for any act relating to the provision of such information,
unless the employer or former employer knowingly provides false information. Such information is
privileged and must not be used as the basis for any action against the person or entity that provided
the information.
Except as otherwise prohibited by federal or state law, an employer or former employer who willfully fails to
disclose any information required by this section is subject to discipline, including, without limitation, a civil
penalty of not more than $10,000 per violation.
In addition to the civil penalty set forth above, a private school that willfully fails to disclose any information required
by this section is subject to discipline, which may include, without limitation, being placed on a plan of corrective action
by the Nevada Department of Education.
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