GDF-ED ©

EXHIBIT

SUPPORT  STAFF  HIRING

BACKGROUND CHECK FORM

Applicant ________________________________     Date  _______________

Person contacted _________________________      Telephone ___________

Address _______________________________________________________

E-mail address  _________________________________________________

Relationship to applicant:

   ◻     Former employer - position  __________________________________

           District, business, or other entity  ______________________________

   ◻     Personal reference

Method of contact:  ◻ Telephone  ◻ Letter  ◻ Other ____________________

QUESTIONS FOR EMPLOYERS

Dates of employment _____________________________________________

Position held  ___________________________________________________

Final rate of pay _________________________________________________

Was the person reliable? ______   If no, explain ________________________

Was the person satisfactory? ______  If no, explain _____________________

Any concern about the person being
late to work without authorization? ___________________________________

If yes, explain ___________________________________________________

Any concern with abuse of leave policies
(such as sick leave or personal leave)? _______________________________

If yes, explain ___________________________________________________

Any difficulty establishing commu-
nication and rapport with children? ___________________________________

If yes, explain  ___________________________________________________

Any difficulties in establishing communication and rap-
port with supervisors, parents, or community members? __________________

If yes, explain ___________________________________________________

Did the person ever receive a written counseling
statement, letter of direction, or reprimand? ____________________________

If yes, describe __________________________________________________

Did the District ever consider taking action or take action
to suspend, decline to renew, or dismiss the employee? __________________

If yes, describe __________________________________________________

Was there ever an allegation or complaint about:

Abusive language? _______________________________________________

Insulting or derogatory comments?  __________________________________

Inappropriate contact with a child? ___________________________________

Verbal or physical contact of a sexual nature? __________________________

Dishonesty?  ____________________________________________________

Substance abuse?  _______________________________________________

Failure to provide adequate supervision? ______________________________

Failure to follow reasonable directions or instructions?  ___________________

If yes on any of the above, get explanation  ____________________________

_______________________________________________________________

Was the person ever involved in an incident
that resulted in injury to an adult or child? ______________________________

If yes, explain ____________________________________________________

Would you rehire this person? _______________________________________

_______________________________________________________________

Can you identify anyone else who could provide relevant infor-
mation regarding the applicant's fitness for employment? __________________

_______________________________________________________________

Is there any other information I have not asked about that
would help us determine this person's eligibility, qualifi-
cations, and suitability for employment with our District? __________________

_______________________________________________________________

QUESTIONS FOR PERSONAL REFERENCE

How long have you known the applicant? ______________________________

What is the nature of your relationship?  _______________________________

Why do you think the applicant would be a good choice for this position?

_______________________________________________________________

Do you know of any reasons that could prevent the ap-
plicant from fulfilling the functions of the position?  _______________________

_______________________________________________________________

Background check form completed by  ________________________________

Date completed __________________________________________________