AUTHORIZATION FOR RELEASE OF EMPLOYEE RECORDS - Oxford Hybrid Secondary School

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Position Applied for::

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Social Security Number

Date / Time

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Current Employer Address

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Previous Employer Address

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NOTE TO CURRENT/PREVIOUS EMPLOYER: Public Act 189 of 1996 requires you to provide Oxford Community Schools copies of any and all information relating to unprofessional conduct contained within the above named personnel file within 20 days of receipt of this request.

certify that n o documentation of unprofessional conduct exists within the above named person’s personnel file.
I have enclosed items relating to unprofessional conduct

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AUTHORIZATION FOR RELEASE OF EMPLOYEE RECORDS

AUTHORIZATION FOR RELEASE OF EMPLOYEE RECORDS
Pursuant to Public Act 189 of Public Acts of 1996
Applicant’s Name: Position Applied for:
Social Security Number: Date:
Personal Address:

Current Employer Name & Address:

Previous Employer Name & Address:

I authorize my current/previous employer to provide to Oxford Community Schools any information in my employment records related to unprofessional conduct. Pursuant to Public Act 189 of the Public Acts of 1996 (Section 380.123-b of the Michigan Compiled Laws), I
authorize my current or former employer to disclose any unprofessional conduct, which is defined as:
One or more acts of misconduct: one or more acts of immorality, moral turpitude, or inappropriate behavior involving a minor, or commission of a crime involving a minor. A criminal conviction is not an essential element of determining whether or not a particular act constitutes unprofessional conduct.
I authorize Oxford Community Schools to obtain disciplinary reports, letters of reprimand, records of disciplinary action, performance evaluations, placement on any program of improvement, and other documents, records, or information contained within my personnel
records with my current or former employer. I understand Public Act 189 of the Public Acts of 1996 provides immunity from civil liability for current or former employers and employees acting on behalf of the current or former employers who act in good faith. I release the
Oxford Community Schools and its representatives from all liability for seeking such information.
I give my current or former employer, including agents thereof, my permission to release the above identified personnel record information without requiring them to contact me or to give me written notice before disclosing the information to the requesting school district. I waive my right of prior notice under the Bullard-Plawecki Employee Right to Know Act, No. 397 of the Public Acts of 1987, Section 423.506 of the Michigan Compiled Laws.
I understand that Oxford Community Schools may share this information with the Oxford Community School Vendor. I understand that if unprofessional conduct has transpired, my employment with an Oxford Community School Vendor is conditioned upon the school district’s review of the personnel records provided and the school district’s determination that nothing therein constitutes a sufficient basis to deny employment. The school district has the sole authority and discretion to determine if involvement and interaction with Oxford Community School students should be denied.
I understand and agree that if I refuse to sign this Authorization and Release of Information regarding any unprofessional conduct by me in my current and/or former employment, the school district is prohibited by law from using my services pursuant to MCL 380.1230(b).

I certify that n o documentation of unprofessional conduct exists within the above named person’s personnel file.
I have enclosed items relating to unprofessional conduct.

Human Resources Office, 10 N. Washington, Oxford, MI 48371. P: 248.969.5001 F: 248.969.5013

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August 19, 2021 7:58 am EST

AUTHORIZATION FOR RELEASE OF EMPLOYEE RECORDS Uploaded by Stan Gibson - stan.gibson@altabright.com IP 104.7.253.106