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The Act 24 PDE 6004 form plays a crucial role in ensuring the safety and integrity of educational environments in Pennsylvania. This standardized document, mandated by the Pennsylvania Department of Education, is required for current and prospective employees of public and private schools, as well as intermediate units and area vocational-technical schools. It serves as a formal mechanism for reporting any arrests or convictions related to specific offenses defined under Pennsylvania law. The form is divided into several sections, beginning with personal information such as full legal name and date of birth. It then prompts individuals to disclose any reportable offenses, providing space to detail the nature of the offenses, including dates, locations, and court information. For those without any arrests or convictions to report, a simple checkbox allows them to state this clearly. The final section emphasizes the importance of accuracy, requiring a signature to certify that the information provided is truthful and complete. Failing to report accurately can lead to serious legal consequences. Understanding the requirements and implications of the PDE 6004 form is essential for anyone involved in the education sector in Pennsylvania.

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ARREST/CONVICTION REPORT AND CERTIFICATION FORM

(under Act 24 of 2011 and Act 82 of 2012)

Section 1. Personal Information

Full Legal Name:

Date of Birth: /

Any former names by which you have been identified:

/

Section 2. Report of Arrest or Conviction

By checking this box, I report that I have been arrested for or convicted of an offense or offenses enumerated under 24 P.S. §§1-111(e) or (f.1) (“Reportable Offense(s)”). See Instructions on Page 3 of this Form for

a list of Reportable Offenses. If you have none to report, proceed to Section 3 of this form.

Details of Arrests or Convictions

For each arrest for or conviction of any Reportable Offense, specify in the space below (or on additional attachments if necessary) the offense for which you have been arrested or convicted, the date and location of arrest and/or conviction, docket number, and the applicable court.

Section 3. No Arrest or Conviction

By checking this box, I state that I have not been arrested for or convicted of any Reportable

Offense.

Section 4. Certification

By signing this form, I certify under penalty of law that the statements made in this form are true, correct and complete. I understand that false statements herein, including, without limitation, any failure to accurately report any arrest or conviction for a Reportable Offense, shall subject me to criminal prosecution under 18 Pa.C.S. §4904, relating to unsworn falsification to authorities.

Signature

Date

PDE-6004 (8/28/2012)

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INSTRUCTIONS

This standardized form (PDE-6004) has been developed by the Pennsylvania Department of Education, pursuant to 24 P.S. §1-111(j), to be used by current and prospective employees of public and private schools, intermediate units and area vocational-technical schools for the written reporting by current and prospective employees of any arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) and (f.1).

As required by subsection (j)(2) of 24 P.S. §1-111, this form shall be completed and submitted by all current and prospective employees of a public or private school, intermediate unit or area vocational-technical school. In addition, as required by subsection (j)(4) of 24 P.S. §1-111, this form shall be utilized by current and prospective employees to provide written notice within seventy-two (72) hours after an arrest or conviction for an offense enumerated under 24 P.S. §§1-111(e) or (f.1).

Exemption: Any current employee who completed a PDE-6004 on or before December 27, 2011, in compliance with 24 P.S. §§1-111(j)(1) and (2) on that date, and who has not been arrested for or convicted of an offense enumerated under 24 P.S. §§1-111(e) and (f.1) shall not be required to complete an additional form.

In accordance with 24 P.S. §1-111, employees completing this form are required to submit the form to the administrator or other person responsible for employment decisions in a school entity.

If you have questions regarding to whom the form should be sent, please contact your supervisor or the school entity administration office.

PROVIDE ALL INFORMATION REQUIRED BY THIS FORM LEGIBLY IN INK.

PDE-6004 (8/28/2012)

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LIST OF REPORTABLE OFFENSES

A reportable offense enumerated under 24 P.S. §1-111(e) consists of any of the following:

(1)An offense under one or more of the following provisions of Title 18 of the Pennsylvania Consolidated Statutes:

Chapter 25 (relating to criminal homicide)

Section 2702 (relating to aggravated assault)

Section 2709.1 (relating to stalking)

Section 2901 (relating to kidnapping)

Section 2902 (relating to unlawful restraint)

Section 2910 (relating to luring a child into a motor vehicle or structure)

Section 3121 (relating to rape)

Section 3122.1 (relating to statutory sexual assault)

Section 3123 (relating to involuntary deviate sexual intercourse)

Section 3124.1 (relating to sexual assault)

Section 3124.2 (relating to institutional sexual assault)

Section 3125( relating to aggravated indecent assault)

Section 3126 (relating to indecent assault)

Section 3127 (relating to indecent exposure)

Section 3129 (relating to sexual intercourse with animal)

Section 4302 (relating to incest)

Section 4303 (relating to concealing death of child)

Section 4304 (relating to endangering welfare of children)

Section 4305 (relating to dealing in infant children)

A felony offense under section 5902(b) (relating to prostitution and related offenses)

Section 5903(c) or (d) (relating to obscene and other sexual materials and performances)

Section 6301(a)(1) (relating to corruption of minors)

Section 6312 (relating to sexual abuse of children)

Section 6318 (relating to unlawful contact with minor)

Section 6319 (relating to solicitation of minors to traffic drugs)

Section 6320 (relating to sexual exploitation of children)

(2)An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as

“The Controlled Substance, Drug, Device and Cosmetic Act.”

(3)An offense SIMILAR IN NATURE to those crimes listed above in clauses (1) and (2) under the laws or former laws of:

the United States; or

one of its territories or possessions; or

another state; or

the District of Columbia; or

the Commonwealth of Puerto Rico; or

a foreign nation; or

under a former law of this Commonwealth.

A reportable offense enumerated under 24 P.S. §1-111(f.1) consists of any of the following:

(1)An offense graded as a felony offense of the first, second or third degree, other than one of the offenses enumerated under 24 P.S. §1-111(e), if less than (10) ten years has elapsed from the date of expiration of the sentence for the offense.

(2)An offense graded as a misdemeanor of the first degree, other than one of the offenses enumerated under 24 P.S. §1-111(e), if less than (5) five years has elapsed from the date of expiration of the sentence for the offense.

(3)An offense under 75 Pa.C.S. § 3802(a), (b), (c) or (d)(relating to driving under influence of alcohol or controlled substance) graded as a misdemeanor of the first degree under 75 Pa.C.S. § 3803 (relating to grading), if the person has been previously convicted of such an offense and less than (3) three years has elapsed from the date of expiration of the sentence for the most recent offense.

PDE-6004 (8/28/2012)

Form Specifications

Fact Name Details
Form Title ARREST/CONVICTION REPORT AND CERTIFICATION FORM
Governing Laws Act 24 of 2011 and Act 82 of 2012
Purpose This form is used by current and prospective employees of educational institutions to report arrests or convictions.
Submission Requirement All current and prospective employees must complete and submit this form.
Exemption Clause Employees who completed the form before December 27, 2011, and have no new reportable offenses are exempt.
Reportable Offenses Includes various serious crimes, such as homicide, assault, and sexual offenses, as outlined in 24 P.S. §1-111(e).
Certification Requirement By signing, individuals certify that the information provided is true and complete.
False Statements Providing false information can lead to criminal prosecution under 18 Pa.C.S. §4904.
Submission Timeline The form must be submitted within 72 hours of an arrest or conviction for a reportable offense.

Act 24 Pde 6004: Usage Guidelines

Completing the Act 24 PDE 6004 form requires careful attention to detail. This form serves as a declaration regarding any arrests or convictions that may impact your eligibility for employment in educational settings. Follow the steps below to ensure that you fill out the form accurately and completely.

  1. Begin with Section 1: Personal Information. Enter your full legal name and date of birth in the designated fields. If you have any former names, list them as well.
  2. Move to Section 2: Report of Arrest or Conviction. If applicable, check the box indicating that you have been arrested or convicted of a reportable offense. If you have no reportable offenses, skip to Section 3.
  3. In the same section, provide detailed information about each arrest or conviction. Include the offense, date and location of the arrest or conviction, the docket number, and the applicable court. Use additional attachments if necessary.
  4. If you have not been arrested or convicted of any reportable offenses, check the box in Section 3 to confirm this.
  5. Proceed to Section 4: Certification. Sign and date the form to certify that all statements are true and complete. Remember that false statements can lead to legal consequences.
  6. Review the entire form for accuracy and completeness before submitting it.
  7. Submit the completed form to the appropriate administrator or person responsible for employment decisions within your school entity.

After filling out the form, ensure that you keep a copy for your records. If you have any questions about the submission process or need clarification on any part of the form, reach out to your supervisor or the school administration office for assistance.

Your Questions, Answered

What is the Act 24 PDE 6004 form?

The Act 24 PDE 6004 form is a standardized document developed by the Pennsylvania Department of Education. It is used by current and prospective employees of public and private schools, intermediate units, and area vocational-technical schools to report any arrests or convictions for specific offenses. This form ensures compliance with state laws regarding the safety and suitability of individuals working in educational settings.

Who is required to complete the PDE 6004 form?

All current and prospective employees of public and private educational institutions in Pennsylvania must complete the PDE 6004 form. This includes teachers, administrators, and support staff. The form must be submitted as part of the employment process, ensuring that all individuals working with students meet the necessary legal requirements.

What types of offenses must be reported on this form?

The form requires reporting any arrests or convictions for offenses listed under 24 P.S. §§1-111(e) and (f.1). These include serious crimes such as homicide, assault, sexual offenses, and certain drug-related charges. A detailed list of reportable offenses is provided in the form's instructions, ensuring clarity on what must be disclosed.

What should I do if I have no arrests or convictions to report?

If you have not been arrested or convicted of any reportable offenses, you should check the appropriate box in Section 3 of the form. This indicates that you have no relevant history to disclose, allowing you to proceed with the rest of the form without additional information regarding criminal history.

What is the deadline for submitting the PDE 6004 form?

The form must be submitted within seventy-two (72) hours of any arrest or conviction for a reportable offense. This requirement ensures that educational institutions can make timely decisions regarding the employment status of individuals based on their legal standing.

What happens if I provide false information on the form?

Providing false information on the PDE 6004 form can lead to serious legal consequences. Under 18 Pa.C.S. §4904, individuals who submit false statements may face criminal prosecution. It is crucial to ensure that all information provided is accurate and complete to avoid potential legal repercussions.

Is there an exemption for employees who completed the form before?

Yes, current employees who completed a PDE 6004 form on or before December 27, 2011, and who have not been arrested or convicted of any reportable offenses since that time are exempt from completing a new form. This exemption helps to streamline the process for individuals who have already been vetted.

How should I fill out the form?

It is important to fill out the PDE 6004 form legibly and completely, using ink. Ensure that all personal information, including your full legal name and date of birth, is accurate. When reporting arrests or convictions, provide detailed information, including the offense, date, location, docket number, and applicable court.

Where do I submit the completed form?

The completed PDE 6004 form should be submitted to the administrator or the person responsible for employment decisions within the school entity. If you are unsure about the appropriate recipient, consult your supervisor or the administration office for guidance.

What resources are available if I have questions about the form?

If you have questions about the PDE 6004 form or the reporting process, it is advisable to reach out to your supervisor or the administration office of your school entity. They can provide clarification and assistance regarding the completion and submission of the form.

Common mistakes

  1. Failing to provide complete personal information. Individuals often overlook the necessity of including their full legal name and any former names. This omission can lead to processing delays.

  2. Misunderstanding the reportable offenses. Many applicants do not fully grasp which offenses must be reported. It is crucial to review the list of reportable offenses carefully to avoid unintentional omissions.

  3. Not including specific details for each arrest or conviction. When detailing offenses, applicants sometimes neglect to provide necessary information such as the date, location, and docket number, which are essential for accurate reporting.

  4. Inaccurately checking the box for no arrests or convictions. Some individuals mistakenly indicate that they have not been arrested or convicted, even when they have. This can lead to serious legal repercussions.

  5. Neglecting to sign and date the form. The certification section requires a signature and date. Failure to complete this step can result in the form being considered incomplete.

  6. Submitting the form to the wrong entity. Individuals sometimes fail to confirm the appropriate administrator or office for submission. This misdirection can delay the processing of their application.

Documents used along the form

The Act 24 PDE 6004 form is essential for reporting any arrests or convictions related to specific offenses as outlined in Pennsylvania law. Alongside this form, several other documents may be required to ensure compliance with legal and educational standards. Below is a list of commonly associated forms and documents.

  • Background Check Authorization Form: This document grants permission for an employer to conduct a background check on an employee or prospective employee. It typically includes personal information and details regarding the scope of the background check.
  • Criminal History Record Check: This report provides a comprehensive history of an individual's criminal background. It is often obtained through state police or other authorized agencies to verify the information provided in the Act 24 PDE 6004 form.
  • Child Abuse Clearance Form: Required for individuals working with children, this form verifies whether a person has a history of child abuse. It is crucial for ensuring the safety of minors in educational settings.
  • Employment Application: This document collects personal and professional information from job applicants. It often includes questions about prior arrests or convictions, serving as an initial screening tool for employers.

Understanding these forms and their purposes can facilitate a smoother application process for individuals seeking employment in educational environments. Each document plays a vital role in maintaining safety and compliance within schools and other institutions.

Similar forms

The Act 24 PDE 6004 form is essential for reporting arrests or convictions for specific offenses in Pennsylvania. It shares similarities with several other legal documents. Here are four such documents:

  • Criminal Background Check Form: This form is used to obtain a detailed report of an individual's criminal history. Like the PDE 6004, it requires individuals to disclose any arrests or convictions, ensuring that employers can assess a candidate's suitability for a position, especially in sensitive roles.
  • Employment Application Disclosure: Many job applications include a section where applicants must disclose any criminal history. This is similar to the PDE 6004 in that both require honesty about past offenses. Failure to disclose can lead to serious consequences, including job termination.
  • Child Abuse Clearance Application: This document is specifically for individuals working with children. It requires applicants to report any criminal history, particularly related to child abuse. The PDE 6004 also focuses on reporting offenses that may affect one's ability to work in educational settings.
  • Probation or Parole Reporting Form: Individuals on probation or parole often must report any new arrests or convictions. This requirement mirrors the PDE 6004, where individuals must report any relevant offenses to maintain compliance with legal obligations.

Dos and Don'ts

When filling out the Act 24 PDE 6004 form, it's important to follow specific guidelines to ensure accuracy and compliance. Here are four things you should and shouldn't do:

  • Do: Provide all required information clearly and legibly.
  • Do: Report any arrests or convictions accurately, as required by the form.
  • Don't: Leave any sections blank unless instructed to do so.
  • Don't: Provide false information or omit details, as this can lead to serious legal consequences.

Misconceptions

Understanding the Act 24 PDE 6004 form is crucial for compliance, yet several misconceptions can lead to confusion. Here are nine common misunderstandings about this form:

  • Only new employees need to fill out the form. This is incorrect. Current employees must also complete the form if they have been arrested or convicted of a reportable offense.
  • All arrests must be reported. Only arrests or convictions for offenses listed under 24 P.S. §§1-111(e) or (f.1) need to be reported. If there are no reportable offenses, you can proceed to the next section.
  • The form is optional. In fact, completing this form is a legal requirement for all current and prospective employees of specific educational institutions.
  • Filling out the form is a one-time process. This is misleading. Employees must submit the form again if they experience a new arrest or conviction for a reportable offense.
  • Submitting the form guarantees employment. While it is necessary to comply with the law, submitting the form does not guarantee that an individual will be hired or retained.
  • It is sufficient to verbally inform the employer about an arrest. Written notice using the PDE 6004 form is required within seventy-two hours of an arrest or conviction.
  • Only serious offenses need to be reported. Any offense listed under the reportable offenses section must be disclosed, regardless of its severity.
  • Providing false information on the form is not a serious issue. False statements can lead to criminal prosecution under Pennsylvania law, which is a serious offense.
  • The form can be submitted to anyone in the organization. It must be submitted to the designated administrator or person responsible for employment decisions within the school entity.

By clarifying these misconceptions, individuals can better navigate the requirements of the Act 24 PDE 6004 form and ensure compliance.

Key takeaways

When filling out and using the Act 24 PDE 6004 form, there are several important points to keep in mind. Understanding these key takeaways can help ensure that the process is smooth and compliant with the law.

  • Complete Personal Information: Provide your full legal name, date of birth, and any former names. This information is crucial for accurate identification.
  • Reportable Offenses: Familiarize yourself with the list of reportable offenses as outlined in the form. Knowing what qualifies as a reportable offense will help you accurately fill out the form.
  • Arrest or Conviction Reporting: If you have been arrested or convicted of a reportable offense, you must check the appropriate box and provide detailed information about each incident.
  • No Arrest or Conviction: If you have not been arrested or convicted of any reportable offense, you can simply check the box indicating this in Section 3.
  • Certification Requirement: By signing the form, you certify that all information provided is true and complete. Misrepresentation can lead to serious legal consequences.
  • Submission Guidelines: Submit the completed form to the designated administrator or person responsible for employment decisions in your school entity.
  • Timeliness: It is essential to submit the form within seventy-two hours of an arrest or conviction, as required by law.
  • Exemptions: Current employees who have previously completed a PDE-6004 form on or before December 27, 2011, and have no new reportable offenses, are not required to fill out a new form.
  • Legibility: Ensure that all information is provided legibly in ink. Illegible forms may lead to delays or complications.

By keeping these takeaways in mind, individuals can navigate the process of completing the Act 24 PDE 6004 form with greater confidence and clarity.