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Name of Registrant: _____________________________________ Date: _______________ Substitute Teacher Registration Checklist NOTE: The cost of substitute authorization is $25.00 ___________ Check ELIS for existing credentials 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. 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. appointment scheduling form and gives form to registrant ROE fills out Bushue Background Screening 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

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Name of Registrant: _____________________________________ Date: _______________

Substitute Teacher Registration Checklist

NOTE: The cost of substitute authorization is $25.00

___________ Check ELIS for existing credentials 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.

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.

appointment scheduling form and gives form to registrant

ROE fills out Bushue Background Screening

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, Fayette, and Effingham Counties Julie Wollerman, Regional Superintendent of Schools

Bill LaDage and Mark Drone, Assistant Regional Superintendents of Schools

300 S. Seventh St., Vandalia, IL 62471 618/283-5011 207 N. Second St. Suite A Greenville, IL 62246 618/664-0121 Fax 618/664-1497

101 N. 4th, Room 204, Effingham, IL 62401 217/342-4363 Fax 217/342-3577

Serving Schools - Protecting Students - Leading for Excellence

To: Substitute Teacher Candidates

From: Julie Wollerman, Regional Superintendent of Schools

RE: Requirements for Substitute Teaching in Bond, Fayette and Effingham Cos.

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 an application. Our offices are equipped to help you on-site with this. Please stop in if you need assistance.

a. $100.00 application fee for each license b. $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 of good 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 authorize a fingerprint criminal history check. Our office will provide all the forms that need to be completed. We forward the information to Bushue Human Resources who does the fingerprinting. This will cost the applicant $52.00 and must be paid at the time of fingerprinting. They accept cash, money order, or credit/debit card. Bushue Human Resources is located at 104 North Second Street in Effingham.

5. 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.

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

300 South Seventh 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.

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.

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 ____ Blue ____ Dark Brown

____ Blonde ____ Brown ____ Fair

____ Brown ____ Green ____ Light Brown

____ Gray ____ Gray ____ Light

____ Sandy ____ Hazel ____ Medium

____ Red ____ Other ____ 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:_______________________________________

Regional Office of Education #3 ~ Bond, Fayette, and Effingham Counties Julie Wollerman, Regional Superintendent of Schools

Bill LaDage and Mark Drone, Assistant Regional Superintendents of Schools

300 S. Seventh St., Vandalia, IL 62471 618/283-5011 207 N. Second St. Suite A Greenville, IL 62246 618/664-0121 Fax 618/664-1497

101 N. 4th, Room 204, Effingham, IL 62401 217/342-4363 Fax 217/342-3577

Serving Schools - Protecting Students - Leading for Excellence

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, Fayette and Effingham 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, Fayette and Effingham Counties to check for my name on the Statewide Illinois Sex Offender Database. I further authorize the Regional Office of Education for Bond, Fayette and Effingham 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, Fayette and Effingham 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, Fayette and Effingham Counties, and that obtaining such certificate does not guarantee that I will be hired as a substitute teacher in Bond, Fayette and Effingham Counties.

Name (Please Print) Date

Signature IEIN or SS #

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 a

credit 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 the

information 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 your

credit-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 identify

information 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, or

unverifiable 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 most

cases, 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 about

you 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 reporting

agency 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 information

in 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, a

user 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 more

information, 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 credit unions also should list, in addition to the Bureau:

a. Bureau of Consumer Financial Protection 1700 G Street NW Washington, DC 20006 b. Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than 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 Foreign Banks, and insured state savings associations d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office 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 Act Nearest 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, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above

FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

A Division of Bushue Human Resources, Inc.

Bushue Background Screening 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. Due to the new school code that went into effect January 1, 2011, all substitute teachers are responsible for the payment of fees for their fingerprinting and criminal background check. Payment is to be made directly to Bushue Background Screening at the time your fingerprints are taken. The fee is $52 and is payable with cash, money order, or credit/debit cards. NO PERSONAL CHECKS WILL BE ACCEPTED.

To schedule an appointment to be fingerprinted, please call our office

at 217-342-3042

Office Hours: M-F 8:00-5:00

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

Substitute Teacher Preference Form Bond-Fayette-Effingham

Regional Office of Education #3: Bond – Fayette -- Effingham

Name: Home Telephone: Cell Phone:

Address: City: Social Security No.

Please specify your school preferences by checking the boxes next to the schools

Bond County Schools

Mulberry Grove High School

Mulberry Grove Jr. High School

Mulberry Grove Elementary School

Bond Co. (Greenville) High School

Greenville Jr. High School

Greenville Elementary School

Pocahontas Elementary School

Sorento Elementary School

Fayette County Schools

Brownstown Jr./Sr. High School

Brownstown Elementary School

St. Elmo High School

St. Elmo Jr. High School

St. Elmo Elementary School

Vandalia High School

Okaw Area Vocational Center

Vandalia Jr. High School

Vandalia Elementary School

Jefferson Primary School

Ramsey High School

Ramsey Elementary School

ROE #3 Alternative Education Programs (Vandalia)

Effingham County Schools

Altamont High School

Altamont Elementary School

Beecher City Jr/Sr High School

Beecher City Elementary School

Dieterich Jr/Sr High School

Dieterich Elementary School

Teutopolis High School

Teutopolis Jr High School

Teutopolis Elementary School

Effingham High School

Effingham Jr. High School

Effingham Central Grade School

South Side Grade School

Early Learning Center

ROE #3 Alternative Education Programs (Effingham)

Other Schools

Altamont Lutheran School

St Peter’s Lutheran School

Vandalia Christian Academy

South Central High School

Sacred Heart Elementary School (Eff.)

St. Anthony High School (Eff.)

St. Anthony Grade School (Eff.)

Substitute Teacher Preference Form Bond-Fayette-Effingham

Regional Office of Education #3: Bond – Fayette -- Effingham

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

Grade Levels Preferred: 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:

Subjects Preferred: Mathematics Science Social Studies P.E. Health

Music Art Technology Special Ed Reading

Language Arts Speech Vocational Business Home Econ.

Other Please Specify:

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

Name of Registrant: _____________________________________ Date: _______________

Substitute Teacher Registration Checklist

NOTE: The cost of substitute authorization is $25.00

___________ Check ELIS for existing credentials 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.

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.

appointment scheduling form and gives form to registrant

ROE fills out Bushue Background Screening

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, Fayette, and Effingham Counties Julie Wollerman, Regional Superintendent of Schools

Bill LaDage and Mark Drone, Assistant Regional Superintendents of Schools

300 S. Seventh St., Vandalia, IL 62471 618/283-5011 207 N. Second St. Suite A Greenville, IL 62246 618/664-0121 Fax 618/664-1497

101 N. 4th, Room 204, Effingham, IL 62401 217/342-4363 Fax 217/342-3577

Serving Schools - Protecting Students - Leading for Excellence

To: Substitute Teacher Candidates

From: Julie Wollerman, Regional Superintendent of Schools

RE: Requirements for Substitute Teaching in Bond, Fayette and Effingham Cos.

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 an application. Our offices are equipped to help you on-site with this. Please stop in if you need assistance.

a. $100.00 application fee for each license b. $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 of good 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 authorize a fingerprint criminal history check. Our office will provide all the forms that need to be completed. We forward the information to Bushue Human Resources who does the fingerprinting. This will cost the applicant $52.00 and must be paid at the time of fingerprinting. They accept cash, money order, or credit/debit card. Bushue Human Resources is located at 104 North Second Street in Effingham.

5. 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.

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

300 South Seventh 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.

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.

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 ____ Blue ____ Dark Brown

____ Blonde ____ Brown ____ Fair

____ Brown ____ Green ____ Light Brown

____ Gray ____ Gray ____ Light

____ Sandy ____ Hazel ____ Medium

____ Red ____ Other ____ 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:_______________________________________

Regional Office of Education #3 ~ Bond, Fayette, and Effingham Counties Julie Wollerman, Regional Superintendent of Schools

Bill LaDage and Mark Drone, Assistant Regional Superintendents of Schools

300 S. Seventh St., Vandalia, IL 62471 618/283-5011 207 N. Second St. Suite A Greenville, IL 62246 618/664-0121 Fax 618/664-1497

101 N. 4th, Room 204, Effingham, IL 62401 217/342-4363 Fax 217/342-3577

Serving Schools - Protecting Students - Leading for Excellence

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, Fayette and Effingham 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, Fayette and Effingham Counties to check for my name on the Statewide Illinois Sex Offender Database. I further authorize the Regional Office of Education for Bond, Fayette and Effingham 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, Fayette and Effingham 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, Fayette and Effingham Counties, and that obtaining such certificate does not guarantee that I will be hired as a substitute teacher in Bond, Fayette and Effingham Counties.

Name (Please Print) Date

Signature IEIN or SS #

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 a

credit 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 the

information 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 your

credit-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 identify

information 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, or

unverifiable 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 most

cases, 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 about

you 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 reporting

agency 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 information

in 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, a

user 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 more

information, 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 credit unions also should list, in addition to the Bureau:

a. Bureau of Consumer Financial Protection 1700 G Street NW Washington, DC 20006 b. Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

2. To the extent not included in item 1 above: a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks b. State member banks, branches and agencies of foreign banks (other than 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 Foreign Banks, and insured state savings associations d. Federal Credit Unions

a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050 b. Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480 c. FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 d. National Credit Union Administration Office 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 Act Nearest 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, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090

9. Retailers, Finance Companies, and All Other Creditors Not Listed Above

FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877) 382-4357

A Division of Bushue Human Resources, Inc.

Bushue Background Screening 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. Due to the new school code that went into effect January 1, 2011, all substitute teachers are responsible for the payment of fees for their fingerprinting and criminal background check. Payment is to be made directly to Bushue Background Screening at the time your fingerprints are taken. The fee is $52 and is payable with cash, money order, or credit/debit cards. NO PERSONAL CHECKS WILL BE ACCEPTED.

To schedule an appointment to be fingerprinted, please call our office

at 217-342-3042

Office Hours: M-F 8:00-5:00

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

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-Fayette-Effingham

Regional Office of Education #3: Bond – Fayette -- Effingham

Name: Home Telephone: Cell Phone:

Address: City: Social Security No.

Please specify your school preferences by checking the boxes next to the schools

Bond County Schools

Mulberry Grove High School

Mulberry Grove Jr. High School

Mulberry Grove Elementary School

Bond Co. (Greenville) High School

Greenville Jr. High School

Greenville Elementary School

Pocahontas Elementary School

Sorento Elementary School

Fayette County Schools

Brownstown Jr./Sr. High School

Brownstown Elementary School

St. Elmo High School

St. Elmo Jr. High School

St. Elmo Elementary School

Vandalia High School

Okaw Area Vocational Center

Vandalia Jr. High School

Vandalia Elementary School

Jefferson Primary School

Ramsey High School

Ramsey Elementary School

ROE #3 Alternative Education Programs (Vandalia)

Effingham County Schools

Altamont High School

Altamont Elementary School

Beecher City Jr/Sr High School

Beecher City Elementary School

Shumway Elementary School

Dieterich Jr/Sr High School

Dieterich Elementary School

Teutopolis High School

Teutopolis Jr High School

Teutopolis Elementary School

Effingham High School

Effingham Jr. High School

Effingham Central Grade School

South Side Grade School

Early Learning Center

ROE #3 Alternative Education Programs (Effingham)

Other Schools

Altamont Lutheran School

St Peter’s Lutheran School

Vandalia Christian Academy

South Central High School

Sacred Heart Elementary School (Eff.)

St. Anthony High School (Eff.)

St. Anthony Grade School (Eff.)

Substitute Teacher Preference Form Bond-Fayette-Effingham

Regional Office of Education #3: Bond – Fayette -- Effingham

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

Grade Levels Preferred: 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:

Subjects Preferred: Mathematics Science Social Studies P.E. Health

Music Art Technology Special Ed Reading

Language Arts Speech Vocational Business Home Econ.

Other Please Specify:

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