WASHINGTON STATE SEXUAL MISCONDUCT
	DISCLOSURE RELEASE

	(District Submits This Form to Previous School District Employer(s))	

To:	SCHOOL DISTRICT EMPLOYER
     	 No prior school district employment	
	PERSONNEL DEPARTMENT
     		
	STREET ADDRESS
     		
	CITY, STATE, ZIP
     		

The named applicant is under consideration for a position in our district.  The Legislature has determined that additional safeguards are necessary in the hiring of school district employees to ensure the safety of Washington’s school children.  The individual whose name appears below has had previous employment with your organization.  As a former employer, we request you provide the information requested on this form within 20 business days as required by state law (RCW 28A.400).  Sexual misconduct definitions are found in WAC 181-87 and WAC 181-88.  Your assistance is appreciated.

APPLICANT’S NAME (FIRST, MIDDLE, LAST)
     	
FULL NAME WHEN LAST EMPLOYED WITH ORGANIZATION
     	
SOCIAL SECURITY NUMBER
     	CERTIFICATE NO.
     	
APPROXIMATE DATES OF EMPLOYMENT
     	
POSITION(S)
     	

I authorize you to release to the school/district listed below, all information related to any acts of sexual misconduct that the school district has made a determination that there is sufficient information to conclude that the abuse or misconduct occurred and that the abuse or misconduct resulted in the employee’s leaving his or her position at the school district.  Such information includes copies of all related documents, including any rebuttal documents, in personnel, investigative or other files, in accordance with RCW 28A.400.  I release the above employer and employees acting on behalf of the employer from any liability for providing information described in this document.

								
Applicant Signature		Date

This section to be completed by former school district employer(s) only.

		No sexual misconduct materials were found.	 	Was a complaint of sexual misconduct
		Yes, sexual misconduct materials are available.		filed with OSPI?		Yes		No
		Please contact for more information.	
		No record of employment

Former Employer Representative Signature		Title		Date				

Employing School Receipt Date      		Received By      					

Return all completed information to:
	SCHOOL DISTRICT
Coulee-Hartline School District 151	
	ADDRESS
410 W Locust	PHONE
509-632-8642	
	STATE	ZIP
Coulee City WA	99115	FAX
509-632-5166	
FORM SPI 1588 (Rev. 6/07)