Name of Registrant: Date:

Substitute Teacher Registration Checklist

NOTE: The cost of substitute authorization is $25.00 Receipt #: ____________

Check ELIS for existing credentials. Reg at ROE 3 thru ____________ IEIN: _____________

Make photocopy of State-issued photo I.D. (e.g., valid driver’s license)

Evidence of recent medical/physical examination or physician's authorization of good health (within previous 90 days as per 105 iLCS 5/24-5) (Give applicant a copy of the Physician's Statement of Good Health Form)

[If needed] Download a Physician's Statement of Good Health Form, have it completed by a

physician and submit it with your paperwork.

Evidence of Mandated Reporter training – Certificate and DCFS Acknowledgement of Status.

Fingerprint Criminal Background Check:

Registrant must read and sign Disclosure and Authorization form and submit to ROE.

Registrant must read and sign Substitute Teacher Authorization Form.

Registrant must be given A Summary of Your Rights Under the Fair Credit Reporting Act. Tell the registrant that this is not a credit history check. It is simply required by the Federal Trade Commission.

ROE fills out Bushue Background Screening appointment scheduling form and gives form to registrant

ROE logs into Bushue Human Resources web page and creates New Order with registrant information. See Bushue HR Guide for details.

ROE fills out Background Check Request form and FAXes the following two documents to

Bushue HR at (217)342-5653:

Background Check Request Form Disclosure and Authorization Form

[OPTIONAL] Substitute fills out Substitute Preference Form and submits to ROE

ROE registrar logs into BushueHR Web Site and Check Reports.

Next page

Print out and save the following:

Statewide Sex Offender Database Check and Statewide Child Murderer and Violent Offender Against Youth Database Check

Illinois State Police will send fingerprint criminal background check results to Regional Superintendent. Regional Superintendent reviews and determines if a substitute authorization certificate will be issued.

When issuing the sub authorization certificate, go into ELIS for the individual and enter in the ROE

Notes section that this initial Substitute Authorization Certificate was "Issued by ROE #3" and include the issue and expiration dates.

If ISP fingerprint criminal background check results are clear, ROE issues a Substitute

Authorization Certificate to registrant with signature and seal.

Add Substitute to ROE online database and flag the "Background Check on File" option

Provide Copy of Background Report to Applicant.

Regional Office of Education #3 Bond, Christian, Effingham, Fayette & Montgomery Counties

Julie Wollerman, Regional Superintendent of Schools Annette Hartlieb, Assistant Regional Superintendents of Schools

1500 W. Jefferson St., Vandalia, IL 62471

618/283-5011 Fax 5013

207 N. Second St. Suite A Greenville, IL 62246

618/664-0121 Fax 1497

101 N. 4th, Room 204, Effingham, IL 62401

217/342-4363 Fax 3577

101 S. Main St., Taylorville, IL 62568

217/824-4730 Fax 2464

203 S. Main St., Hillsboro, IL 62049

217/532-9591 Fax 5756

To: Substitute Teacher Candidates

From: Julie Wollerman, Regional Superintendent of Schools

RE: Requirements for Substitute Teaching in Bond, Christian, Effingham, Fayette and Montgomery Counties

Here are the requirements for substitute teacher candidates:

1. You must hold a valid Illinois Professional Educator License (PEL) or Educator License with Stipulations(ELS - substitute license). To apply for either, you must log into ELIS via www.isbe.net and complete anapplication. Our offices are equipped to help you on-site with this. Please stop in if you needassistance.

a. $50.00 application fee for each licenseb. $50.00 registration ($10 per year/5 years) fee for the period of validity

Once you have been awarded your license and paid registration fees, you are eligible to substitute teach. However, all schools now require background checks and health papers for you to work in their district. To avoid providing such paperwork (at your cost) to each district, you can obtain an ROE 3 Substitute Teacher Authorization. This allows you to present the paperwork one time to the ROE instead of each district as we are authorized by law to share background checks with districts. The steps for obtaining an ROE 3 Substitute Teacher Authorization are:

2. You must present evidence of a recent medical/physical examination or physician's authorization ofgood health (within previous 90 days as per state law 105 ILCS 5/24-5).

3. You must present a valid driver's license or state issued photo ID.

4. You must complete the online Mandated Reporter Training through DCFS. This is a free training available online.If you do not have Internet access, you can take the training at one of our offices. Please allow at least 90minutes. Once you complete the training, be sure to print off your completion certificate. You will also sign anacknowledgement form that you understand the responsibilities that come with being a mandated reporter.

5. You must authorize a fingerprint criminal history check. Our office will provide all the forms that need to becompleted. We forward the information to Bushue Human Resources who does the fingerprinting. This willcost the applicant $52.00 (cash) or $54.00 (debit/credit) and must be paid at the time of fingerprinting.They accept cash, money order, or credit/debit card. Bushue Human Resources is located at 302 E.Jefferson Ave. Suite B in Effingham.

6. You must pay a $25 processing fee for issuance of an ROE 3 Substitute Teacher Authorization.

Our office will also ask if you wish to have your name and contact information added to our online substitute teacher database. This is optional. This database is used by our districts when seeking substitute teachers and paraprofessionals. It does not, however, take the place of an individual visit by you. We recommend that you visit each district/school that you have an interest in subbing at and introduce yourself to the administrative staff.

Serving Schools ~ Protecting Students ~ Leading for Excellence

PHYSICIAN’S STATEMENT OF GOOD HEALTH

The * Illinois School Code requires that new employees show evidence of physical fitness to perform duties assigned to them. Any cost shall rest with the employee.

I hereby certify that meets the above requirement of physical fitness.

Date Signature M.D.

Address

City Zip

Please return to: Regional Office of Education 1500 W. Jefferson Street Vandalia, IL 62471

Phone: (618) 283-5011 Fax: (618) 283-5013

* (105 ILCS 5/24-5) (from Ch. 122, par. 24-5)Sec. 24-5. Physical fitness and professional growth. (a) In this Section, "employee" means any employee of a school district, a student teacher, an employee of a contractor

that provides services to students or in schools, or any other individual subject to the requirements of Section 10-21.9 or 34- 18.5 of this Code.

(b) School boards shall require of new employees evidence of physical fitness to perform duties assigned and freedom from communicable disease. Such evidence shall consist of a physical examination by a physician licensed in Illinois or any other state to practice medicine and surgery in all its branches, an advanced practice nurse who has a written collaborative agreement with a collaborating physician that authorizes the advanced practice nurse to perform health examinations, or a physician assistant who has been delegated the authority to perform health examinations by his or her supervising physician not more than 90 days preceding time of presentation to the board, and the cost of such examination shall rest with the employee. A new or existing employee may be subject to additional health examinations, including screening for tuberculosis, as required by rules adopted by the Department of Public Health or by order of a local public health official. The board may from time to time require an examination of any employee by a physician licensed in Illinois to practice medicine and surgery in all its branches, an advanced practice nurse who has a written collaborative agreement with a collaborating physician that authorizes the advanced practice nurse to perform health examinations, or a physician assistant who has been delegated the authority to perform health examinations by his or her supervising physician and shall pay the expenses thereof from school funds.

(c) School boards may require teachers in their employ to furnish from time to time evidence of continued professional growth. (Source: P.A. 98-716, eff. 7-16-14.)

FINGERPRINTING - DISCLOSURE AND AUTHORIZATION [IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]

NOTICE REGARDING BACKGROUND INVESTIGATION ROE #3 (“the ROE”) may obtain information about you from a consumer reporting agency for purposes of employment, licensure, volunteering, student teaching, or any other contractual services. These reports may contain information regarding your criminal history, motor vehicle records (“driving records”), fingerprint test by state police and/or FBI, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any consumer report. Please be advised that the nature and scope of the most common form of consumer report obtained with regard to applicants, volunteers, and contractors is a fingerprint test and photo recognition by the state police and/or FBI conducted by Bushue Human Resources, Inc., 104 N. Second St., Suite B, Effingham, IL 62401, (217) 342-3042, or toll free at (877) 342-3042, or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing ROE #3 to obtain from any outside organization all manners of consumer reports and investigative consumer reports now and throughout the course of your employment or service to the ROE to the extent permitted by law.

ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the ROE at any time after receipt of this authorization and throughout my employment and/or service, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Bushue Human Resources, Inc., 104 N. Second St., Suite B, Effingham, IL 62401, (217) 342-3042, or toll free at (877) 342- 3042, another outside organization acting on behalf of ROE #3, and/or the ROE itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

Last Name First Middle Maiden/Other Alias

**Social Security # _**Date of Birth Driver’s License # State of Driver’s License

Present Address City/State/Zip

Signature: _Date: Phone_

**This information will be used for background screening purposes only and will not be used as hiring criteria.

Gender: Male Race: Asian Pacific Islander Height: Female Black White Hispanic Weight:

White Place of Birth (State): Other

Hair Color: Bald Eye Color: Black Skin Tone: Black Black Blonde Brown Gray Sandy Red

Blue Brown Green Gray Hazel Other

Dark Brown Fair Light Brown Light Medium Olive

Position: Please Circle (all that apply): Certified - Non-Certified - Student Teacher - Bus Driver Per Illinois School Code you are entitled to receive a copy of your criminal background check. Would you like to receive this copy? Yes No

Office Use Only: Proof of Identity: DL / State I.D. / Passport / Birth Certificate / SSC / Other: ORI #: IL003E03S or SB0261004

Technician: Technician License #: 249.0000 TCN:

Date of Fingerprinting: Time: Location:

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by ROE #3 by contacting the consumer reporting agency identified above directly.

Regional Office of Education #3 Bond, Christian, Effingham, Fayette & Montgomery Counties

Julie Wollerman, Regional Superintendent of Schools Annette Hartlieb, Assistant Regional Superintendents of Schools

1500 W. Jefferson St., Vandalia, IL 62471

618/283-5011 Fax 5013

207 N. Second St. Suite A Greenville, IL 62246

618/664-0121 Fax 1497

101 N. 4th, Room 204, Effingham, IL 62401

217/342-4363 Fax 3577

101 S. Main St., Taylorville, IL 62568

217/824-4730 Fax 2464

203 S. Main St., Hillsboro, IL 62049

217/532-9591 Fax 5756

SUBSTITUTE TEACHER AUTHORIZATION FORM Section 10-21.9 of Illinois School Code requires all applicants for employment with a school district including persons who or firms holding contracts with the district, who have direct daily contact with the pupils of any district school, to authorize a fingerprint-based criminal history records check to determine if the applicant has been convicted of certain enumerated offenses, and a check of criminal databases. A school board shall not knowingly employ a person for whom a criminal background investigation has not been initiated.

I authorize the Regional Office of Education for Bond, Christian, Effingham, Fayette and Montgomery Counties to submit fingerprints and other necessary information electronically to the Illinois State Police (ISP) and the Federal Bureau of Investigation (FBI) via Bushue Human Resource, Inc. to conduct a criminal background check. I further authorize the Regional Office of Education for Bond, Christian, Effingham, Fayette and Montgomery Counties to check for my name on the Statewide Illinois Sex Offender Database.

I further authorize the Regional Office of Education for Bond, Christian, Effingham, Fayette and Montgomery Counties to check for my name on the Illinois Statewide Child Murderer and Violent Offenders Against Youth Database.

I understand that conviction on any of the enumerated offenses or the presence of your name on any of these reports will exclude me from substitute teaching in Bond, Christian, Effingham, Fayette and Montgomery County schools and could result in the suspension, revocation, or surrender of my teaching certificate(s).

I understand that the Regional Superintendent shall share criminal history reports with the Superintendent of a School District, other Regional Superintendents, the State Superintendent of Schools, and the State Teacher Certification Board. I further understand that a copy of the criminal history check shall be provided to me if requested.

I understand that I am responsible for the payment of the cost of the criminal history check and checks of the Statewide Sex Offender Database and Statewide Child Murderer and Violent Offender Against Youth Database.

I understand that receiving a Substitute Authorization Certificate is necessary to substitute teach in Public Schools of Bond, Christian, Effingham, Fayette and Montgomery Counties, and that obtaining such certificate does not guarantee that I will be hired as a substitute teacher in Bond, Christian, Effingham, Fayette and Montgomery Counties.

Name (Please Print) Date

Signature IEIN or SS #

Serving Schools ~ Protecting Students ~ Leading for Excellence

Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

A Summary of Your Rights Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.

• You must be told if information in your file has been used against you. Anyone who uses acredit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all theinformation about you in the files of a consumer reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

• a person has taken adverse action against you because of information in your credit report;• you are the victim of identify theft and place a fraud alert in your file;• your file contains inaccurate information as a result of fraud;• you are on public assistance;• you are unemployed but expect to apply for employment within 60 days.

In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of yourcredit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identifyinformation in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete, orunverifiable information. Inaccurate, incomplete or unverifiable information must be removed

or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In mostcases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A consumer reporting agency may provide information aboutyou only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A consumer reportingagency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

• You may limit “prescreened” offers of credit and insurance you get based on informationin your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567- 8688.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, auser of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For moreinformation, visit www.consumerfinance.gov/learnmore.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

TYPE OF BUSINESS: CONTACT: 1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates.

b. Such affiliates that are not banks, savings associations, or creditunions also should list, in addition to the Bureau:

a. Bureau of Consumer Financial Protection1700 G Street NW Washington, DC 20006

b. Federal Trade Commission: Consumer Response Center – FCRAWashington, DC 20580 (877) 382-4357

2. To the extent not included in item 1 above:

a. National banks, federal savings associations, and federal branchesand federal agencies of foreign banks

b. State member banks, branches and agencies of foreign banks (otherthan federal branches, federal agencies, and insured state branches of foreign banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

c. Nonmember Insured Banks, Insured State Branches of ForeignBanks, and insured state savings associations

d. Federal Credit Unions

a. Office of the Comptroller of the CurrencyCustomer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050

b. Federal Reserve Consumer Help CenterP.O. Box 1200 Minneapolis, MN 55480

c. FDIC Consumer Response Center1100 Walnut Street, Box #11 Kansas City, MO 64106

d. National Credit Union AdministrationOffice of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Department of Transportation 400 Seventh Street SW Washington, DC 20590

4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 1925 K Street NW Washington, DC 20423

5. Creditors Subject to Packers and Stockyards ActNearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC 20416

7. Brokers and Dealers Securities and Exchange Commission 100 F St NE Washington, DC 20549

8. Federal Land Banks, Federal Land Bank Associations, FederalIntermediate Credit Banks, and Production Credit Associations

9. Retailers, Finance Companies, and All Other Creditors Not ListedAbove

Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090 FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

Bushue Background Screening A Division of Bushue Human Resources, Inc.

Is the fingerprinting/background screening provider for

Regional Office of Education #3 A fingerprint criminal check is a requirement by the Illinois School Code. Background checks are conducted through the submission of fingerprints to the Illinois State Police and FBI.

Payment is to be made directly to Bushue Background Screening at the time your fingerprints are taken. The fee is $52 (cash) or $54 (debit/credit) and is payable with cash, money order, or credit/debit cards. NO PERSONAL CHECKS WILL BE ACCEPTED.

Please bring a valid driver’s license on the day your prints are to be conducted.

****************************************************************** MANDATED REPORTER TRAINING

The free mandated reporter training through DCFS is available online here –

https://mr.dcfstraining.org/UserAuth/Login!loginPage.action;jsessionid=2D158C94E3DBE1EB437789C9ECC29A1D

or search “Free mandated reporter training DCFS”. You will create an account so you can return to the training later if you are interrupted or need access to your completion certificate. Please allow 90 minutes for the training AND have access to a printing device for your completion certificate once the training is completed.

To schedule an appointment to be fingerprinted, please call 217-342-3042 Hours: M-F 8:00-5:00

Bushue Human Resources

302 E. Jefferson Ave. Suite B, Effingham, IL 62401

B A C K G R O U N D C H E C K R E Q U E S T

COVER SHEET

TO: FROM:

Bushue Human Resources, Inc. ROE #3 FAX NUMBER: DATE:

217-342-5653 PHONE NUMBER: TOTAL NO. OF PAGES INCLUDING COVER:

217-342-3042 RE: EMPLOYEE/APPLICANT NAME:

Background Check Request

Services to Provide: Please indicate in the boxes below the background check(s) you are requesting:

School District Employee (certified employee) State and Federal Fingerprint Background Check State and Federal Sex Offender Check Violent Offender Against Youth Database

School District Employee (non-certified employee) State and Federal Fingerprint Background Check State and Federal Sex Offender Check Violent Offender Against Youth Database

Student Teacher (non-certified employee) State and Federal Fingerprint Background Check State and Federal Sex Offender Check Violent Offender Against Youth Database

School District Bus Driver State and Federal Fingerprint Background Check State and Federal Sex Offender Check Violent Offender Against Youth Database

Motor Vehicle Record Check

Volunteer Background Check (non-fingerprint) State and Federal Sex Offender Check Violent Offender Against Youth Database

I, , (print name) authorize Bushue Human Resources, Inc. to conduct the requested background check and return the results to ROE #3.

Signature of Requesting District Employee Date

Substitute Teacher Preference Form: Bond, Christian, Effingham, Fayette & Montgomery

Regional Office of Education #3: Bond, Christian, Effingham, Fayette & Montgomery Counties

Name: Home Telephone: Cell Phone:

Address: City: Social Security No. IEIN:

Email Address County of Residence:

Please specify your school preferences by checking the boxes next to the schools Bond County Schools Mulberry Grove High School Bond Co. (Greenville) High School

Mulberry Grove Jr. High School Greenville Jr. High School

Mulberry Grove Elementary School Greenville Elementary School

Pocahontas Elementary School

Sorento Elementary School

Christian County Schools Morrisonville Jr/Sr High School Edinburg Schools

Morrisonville Elementary School

Pana High School Taylorville High School

Pana Jr High School Taylorville Jr. High School

Lincoln Elementary School Memorial Elementary School

Washington Elementary School North Elementary School

Stonington Elementary SchoolSouth Fork High School Central School South Fork Jr High School

South Fork Elementary School

Effingham County Schools Altamont High School Beecher City Jr/Sr High School

Altamont Elementary School Beecher City Elementary School

Dieterich Jr/Sr High School Effingham High School

Dieterich Elementary School Effingham Jr. High School

Effingham Central Grade School

Teutopolis High School South Side Grade School

Teutopolis Jr High School Early Learning Center

Teutopolis Elementary School Aspire Alternative High School (Effingham)

TriStar Academy Safe Schools Program (Effingham)

Substitute Teacher Preference Form: Bond, Christian, Effingham, Fayette & Montgomery

Regional Office of Education #3: Bond, Christian, Effingham, Fayette & Montgomery Counties

Fayette County Schools Brownstown Jr./Sr. High School

Brownstown Elementary School

Vandalia High School

Okaw Area Vocational Center

Vandalia Jr. High School

Vandalia Elementary School

St. Elmo High School

St. Elmo Jr. High School

St. Elmo Elementary School

Ramsey High School

Ramsey Elementary School

New Approach Alternative High School (Vandalia)

FOCUS Safe Schools Program (Vandalia)

Montgomery County Schools Lincolnwood High School Hillsboro High School

Lincolnwood Jr. High School Hillsboro Jr. High School

Farmersville Grade School Beckemeyer Elementary School

Raymond Grade School Coffeen Elementary School

Litchfield High School Nokomis Senior High School

Litchfield Middle School Nokomis Jr High School

J.D. Colt Elementary School North Elementary School

Madison Park Elementary School

Ida J. Russell Elementary School

Litchfield Pre-Kindergarten

Other Schools Altamont Lutheran School Sacred Heart Elementary School (Eff.)

St Peter’s Lutheran School St. Anthony High School (Eff.)

Vandalia Christian Academy St. Anthony Grade School (Eff.)

South Central High School St. Louis Catholic School (Nokomis)

Sacred Heart (Pana) Zion Lutheran School (Litchfield)

St. Mary School (Taylorville) Visionway Christian School (Taylorville)

First Baptist Christian Academy (Pana)

Substitute Teacher Preference Form: Bond, Christian, Effingham, Fayette & Montgomery

Regional Office of Education #3: Bond, Christian, Effingham, Fayette & Montgomery Counties

Grade Levels Preferred:

Subjects Preferred:

Other Please Specify:

Please specify your grade level preferences by checking all grade levels that apply:

Pre-K or K Grade 1 Grade 2 Grade 3 Grade 4

Grade 5 Grade 6 Grade 7 Grade 8 Grade 9

Grade 10 Grade 11 Grade 12

Please specify your subject area preferences by checking all subject areas that apply:

Mathematics Science Social Studies P.E. Health Music Art Technology Special Ed Reading Language Arts Speech Vocational Business Home Econ.

Please indicate any other preferences or criteria that you would like made available to prospective employers:

Office of the Director 406 E. Monroe Street • Springfield, Illinois 62701

www.DCFS.illinois.gov

ACKNOWLEDGEMENT OF MANDATED REPORTER STATUS

I, , understand that when I am employed as a (Employee Name)

, I will become a mandated reporter under the (Type of Employment)

Abused and Neglected Child Reporting Act [325 ILCS 5/4]. This means that I am required to report or cause a report to be made to the child abuse Hotline number at 1-800-25-ABUSE (1-800-252-2873) whenever I have reasonable cause to believe that a child known to me in my professional or official capacity may be abused or neglected. I understand that there is no charge when calling the Hotline number and that the Hotline operates 24-hours per day, 7 days per week, 365 days per year.

I further understand that the privileged quality of communication between me and my patient or client is not grounds for failure to report suspected child abuse or neglect, I know that if I willfully fail to report suspected child abuse or neglect, I may be found guilty of a Class A misdemeanor. This does not apply to physicians who will be referred to the Illinois State Medical Disciplinary Board for action.

I also understand that if I am subject to licensing under but not limited to the following acts: the Illinois Nursing Act of 1987, the Medical Practice Act of 1987, the Illinois Dental Practice Act, the School Code, the Acupuncture Practice Act, the Illinois Optometric Practice Act of 1987, the Illinois Physical Therapy Act, the Physician Assistants Practice Act of 1987, the Podiatric Medical Practice Act of 1987, the Clinical Psychologist Licensing Act, the Clinical Social Work and Social Work Practice Act, the Illinois Athletic Trainers Practice Act, the Dietetic and Nutrition Services Practice Act, the Marriage and Family Therapy Act, the Naprapathic Practice Act, the Respiratory Care Practice Act, the Professional Counselor and Clinical Professional Counselor Licensing Act, the Illinois Speech-Language Pathology and Audiology Practice Act, I may be subject to license suspension or revocation if I willfully fail to report suspected child abuse or neglect.

I affirm that I have read this statement and have knowledge and understanding of the reporting requirements, which apply to me under the Abused and Neglected Child Reporting Act.

Signature of Applicant/Employee

Date CANTS 22 Rev. 8/2013