Pde 338 G Form - Background Collection Form printable pdf download

Pennsylvania Emergency Permit Re-issuance

Background Collection Form PDE 338 G

(For 04 Long-Term Substitutes with No Education Obligation or 06 Day-to-Day Substitutes)

(Refer to the instructions included with this two-page form)

Section I – Personal Information (please print or type)

1. Last Name

First Name

Middle Initial

2. Pennsylvania Personnel ID (PPID)

3. Address

4. Date of Birth (mm/dd/yyyy)

City/State/Zip Code

5. Daytime Telephone

6. E-Mail Address

(

)

(

)

Home/Cell

Work Phone

7. Please list all former name(s) beginning with the most recent

8. Are you a United States Citizen?

□

Yes

_________________________________

________________________

______

□

No - If you check this box you

must apply online using the

_________________________________

________________________

______

Teacher Information Management

Last

First

System (TIMS) unless teaching a

World Language

Section II-Background

Read and answer each question carefully to ensure that you have selected the appropriate check box. Incorrectly

checking a box may significantly delay the processing of your application. Please refer to the instruction sheet for

further information.

Yes:

□ Pending

1. Have you ever been the subject of a child abuse investigation or report in this or any other

□ Unfounded

state, territory or country? (If yes, read the instructions for this question first, then indicate

□ Indicated

whether the investigation or report is pending, unfounded, indicated, or founded by checking

□

the appropriate box.)

Founded

□

□ Yes

2. Are you currently the subject of any misconduct investigation by an employer?

□

(If yes, refer to instructions.)

3. Have you ever resigned from or otherwise left any employment (e.g., settlement agreement)

□ Yes

while allegations of misconduct were pending, or under investigation?

(If yes, refer to

□

instructions.)

□ Yes

4. Is there disciplinary action pending by a licensing agency in this or any other state, territory,

□

or country? (If yes, refer to instructions.)

5. Have you ever had any certificate or license for any profession denied, revoked,

□ Yes

suspended, surrendered, or received a public reprimand in this or any other state, territory,

□

or country?

(If yes, refer to instructions.)

Revised: August 2015

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Pde 338 G Form - Background Collection Form

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