administrative center human resources

Better Schools Build Better Communities www.champaignschools.org/employment

Administrative Center

Human Resources

502 West Windsor Road Telephone: (217) 351-3822 Champaign, Illinois 61820 Fax: (217) 351-7386

July 27, 2021

Dear College/University Student:

We are excited to have you join us here in Champaign Unit 4 Schools! Our buildings are wonderful places for you to

learn and grow alongside our fantastic students, staff, families, and community members.

As we prepare to welcome you, there are a few things we need from you to ensure your experience is as enjoyable as

possible and to protect our students’ safety and welfare.

The following pages contain checklists of what you’re required to do prior to beginning your experience in Unit 4.

In addition to being available on the Human Resources page of our website (www.champaignschools.org/hr), this

information is also provided electronically to college/university contacts for distribution to their prospective Student-

Teachers and Student Observers.

Colleges and universities use a variety of terms to identify students engaged in preliminary level “hands on” work in

schools as part of a licensure program. Champaign Unit 4 Schools groups all Field-based, Practicum, Doctoral, Pre-

Clinical, Clinical, and Nursing placements under the “Student Observer” heading. College/University students who are

doing “full takeover” work are considered Student-Teachers.

The checklists that follow are divided into two sections: one section for Student Observers (pp. 2-11) and one section

for Student-Teachers (pp. 12-17). Please be sure to complete the correct requirements based on your placement

and allow plenty of time to get everything done.

Once you are approved to be in our schools, we want to make you aware of our Sign In/Sign Out procedures. Student

Observers are expected to sign in and out every time they visit a Unit 4 building. There is a section of our official

Volunteer Log Book at each campus designated for you to do so. Student-Teachers are not required to sign in and out

daily unless directed to do so by their Cooperating Teacher or Administrator.

If you have questions about any information in this packet, please call the Champaign Unit 4 Schools Human Resources

Office at (217) 351-3822 or email [email protected].

If you are interested in learning more about career opportunities while you are in school or once you are licensed, feel

free to contact our Talent Recruitment & Retention Manager, Ms. Jeffonne (Jey) Owens, at (217) 722-2070. She would

be happy to discuss the possibilities with you!

We look forward to seeing you in our schools and appreciate your interest in our District.

Sincerely,

Dan Casillas Jey Owens

Director of Human Resources Development Talent Recruitment & Retention Manager

Ken Kleber

Assistant Superintendent of Human Resources & Organizational Effectiveness

http://www.champaignschools.org/hr

mailto:[email protected]



Human Resources


College/University Student Observer* Paperwork Requirements The following forms must be completed before you can begin your field experiences in Champaign Unit 4

Schools. Completed forms can be turned in at the front desk of the Unit 4 Administrative Center (located at

502 West Windsor Road in Champaign) during normal business hours.

1. Student-Teacher and Student Observer* Information Sheet & Acknowledgements

This form provides the District with general information about you and your placement and helps

you better understand the expectations we have for you during your time in our buildings.

This fully completed form should be turned in along with Item #2. The District will NOT conduct

a background check without the Information Sheet & Acknowledgements on file.

2. Background Check Disclosure and Authorization Form and Summary of Rights

All Student Observers* must successfully complete a name-based criminal background check prior

to beginning observations. The attached Disclosure for Consumer Reports and Authorization for

Consumer Reports forms must be completed and initialed by you. The BHR Screen form must be

signed by you. A computer signature is not acceptable. The cost of the background check will be

covered by the District. The Summary of Rights document is yours to keep.

Please note that we contract with Bushue Background Screening to conduct background checks for

this program. Bushue operates under the Fair Credit Reporting Act (FCRA) and is required to

provide you with notice of this, but a traditional credit check is not performed as part of the Unit 4

process.

Once you have cleared your background check, you will receive a clearance email from our

Fingerprint Technician. This email serves as your final authorization to begin your placement in our

buildings. It should be provided to your Cooperating Teacher(s) on or before the date your

placement begins. You will not be permitted to begin your field experience without it!

(Note: If you have not received a clearance email one week before your scheduled start date, please

call our office to inquire on your status.)

The District maintains a database of Student Observers who have cleared background checks. If you return

to our building for another semester of observation, you will only be required to complete Item #1 again.

(Please note that if you are placed as a Student Teacher in our District, you will be required to undergo a

second background check since the check conducted is different for Student Teachers.)

*Colleges and universities use a variety of terms to identify students engaged in preliminary level “hands on”

work in schools as part of a licensure program. Champaign Unit 4 Schools groups all Field-based,

Practicum, Doctoral, Pre-Clinical, Clinical, and Nursing placements under the “Student Observer” heading.

College/University students who are doing “full takeover” work are considered Student-Teachers.

Last Revised June 23, 2020

CHAMPAIGN COMMUNITY UNIT SCHOOL DISTRICT NO. 4 CHAMPAIGN, ILLINOIS

Student-Teacher and Student Observer* Information Sheet & Acknowledgements

* Colleges and universities use a variety of terms to identify students engaged in preliminary level “hands on” work in schools as part of a licensure program. Champaign Unit 4 Schools groups all Field-based, Practicum, Doctoral, Pre-Clinical, Clinical, and Nursing placements under the “Student Observer” heading. College/University students who are doing “full takeover” work are considered Student-Teachers.

Personal Information Last Name First Name Middle Initial Email Address

Present Street Address

City State Zip Phone

( )

Gender

Race/Ethnicity

African American American Indian/Alaskan Hispanic White Asian/Pacific Islander Multi-Racial

College/University Information Unit 4 Placement Information

Placement Start Date

__________________________

Placement End Date

__________________________

Cooperating College/University

____________________________________

College/University Contact Name/Email

____________________________________

____________________________________

Cooperating Unit 4 Teacher(s)

____________________________________

Assigned Unit 4 Building(s)

____________________________________

Grade Level(s)/Subject(s)

____________________________________

Have you previously been placed as a Student-Teacher or Student-Observer in Champaign Unit 4 Schools? (check all that apply) Yes, as a Student Observer Yes, as a Student-Teacher No

In which capacity will you be visiting Unit 4 Schools (see definitions above)? Student Observer* Student-Teacher

Are you interested in receiving information via email from the Champaign Unit 4 Schools Human Resources Department regarding professional networking and professional growth opportunities, along with information about District vacancies? Yes No

Background Information (You Are Not Obligated To Disclose Sealed Or Expunged Records Of Conviction Or Arrest) Have you ever been convicted of any misdemeanor (excluding traffic violations)? If yes, explain. Attach additional sheets, if necessary.

Yes No

Have you ever been convicted of any felony? If yes, explain. Attach additional sheets, if necessary.

Yes No

Have you ever had an indicated finding of child abuse in your name? If yes, explain. Attach additional sheets, if necessary.

Yes No

Mandated Reporter Information

Champaign Unit 4 Schools considers Student Observers and Student Teachers mandated reporters of child abuse and neglect. More information about mandated reporting and training materials can be found at https://mr.dcfstraining.org. By checking the box to the right, you acknowledge that you are expected to report suspected child abuse and neglect. (Please note that your college or university may require additional documentation regarding mandated reporting.)

I understand that I am expected

to report child abuse/neglect.

https://mr.dcfstraining.org/

District Expectations for Student-Teachers and Student Observers* The following are some general expectations the District has for all Student-Teachers and Student Observers*. In addition to the expectations below, Student-Teachers and Student Observers* are expected to abide by all Federal, State, and local laws, as well as the policies and procedures of the Board of Education of Champaign Unit 4 Schools. Additionally, Student-Teachers and Student Observers* are expected to comply with directives from Administration and their Cooperating Teachers. The authority of school personnel, rules, and guidelines should be supported and followed at all times. Any questions, concerns, or observations regarding any rule or guideline may be taken professionally and privately to your Cooperating Teacher or Administrator. Signing In and Out Student Observers* are expected to sign in and out every time they visit a Unit 4 building. There is a section of our official Volunteer Log Book at each campus designated for you to do so. Student-Teachers are not required to sign in and out daily unless directed to do so by their Cooperating Teacher or Administrator. Report Time & Attire If you are unable to be on campus when your Cooperating Teacher or Administrator is expecting you, you should let them know in advance (to the extent possible). Attire must be appropriate for a professional educational environment. Seek guidance from your Cooperating Teacher or Administrator. Interacting with Students All interactions with students will take place on school grounds within view of school personnel or in a room with an open door or within view of a door’s window. Off campus contact is prohibited (including telephone or computer-based interaction), unless specifically authorized by the Cooperating Teacher or Administrator. Your personal contact information should not be shared with any student. Physical Contact Physical contact with the students will be limited, professional, and age appropriate for the child. Remember that what is intended to be simple, friendly affection may be perceived as something entirely different by the student or an observer. If a child persists in being inappropriately physical, please seek the assistance of a staff member immediately. Transportation Transporting a student in a personal vehicle is prohibited. Students must be transported in a District vehicle (field trips), in a school official’s vehicle, or in a parent or legal guardian’s vehicle. Student-Teachers and Student Observers* should not be alone with any student in any vehicle. Confidentiality All things regarding a student and his/her family which are heard or seen at school are confidential and should not be discussed outside of the school environment. They should only be discussed within the school environment when educationally necessary. All confidential information is protected by FERPA (the Family Educational Rights and Privacy Act). Sharing information with others is a violation of the law; however, if a student confides that he or she is the victim of abuse, is considering homicide or suicide, is being bullied or is bullying others, or is involved in any illegal activity, a school official MUST be notified immediately! (Check with your Cooperating Teacher or Administrator if you are unsure to whom to report this information.) It is wise to write down the information, including the date and to whom the information was reported. Remember, this information is extremely personal and capable of damaging lives, so do not share it with anyone except the appropriate school personnel. Please note that reporting information to your Cooperating Teacher or Administrator is separate from the expectation that you report required information to the Department of Children and Family Services (DCFS) as a Mandated Reporter. Important District Policies

Drug-Free Workplace Policy: No person shall unlawfully possess, use, dispense, distribute or manufacture any controlled substance in the workplace.

Use of Tobacco: The use of tobacco in any form is prohibited on all District property.

Sexual Harassment: It is the policy of the Board of Education that sexual harassment of students/employees of the district shall not be permitted. This includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature that substantially interfere with work performance or create an intimidating, hostile, or offensive work environment.

I have read this document completely and understand all the information contained in it. I certify that the facts contained in this form are true and complete. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for removal from Student Observation or Student-Teaching, no matter when discovered by Champaign Community Unit School District No. 4. Signature of Student-Teacher/Student Observer*: _________________________________________________ Date: ________________________

FOR OFFICE USE ONLY

Notes:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________




Human Resources


DISCLOSURE FOR CONSUMER REPORTS

READ CAREFULLY BEFORE SIGNING

Champaign Unit 4 (“end-user”) has contracted with Bushue Background Screening in connection with my

application for employment, volunteerism, contracted services, tenancy, enrollment, acceptance into a

program, student observing/teaching, and/or other reasons. I understand consumer reports will be requested

by you the end-user. These reports may include, as allowed by law, the following types of information, as

applicable: names and dates of previous employers, reason for termination of employment, work experience,

reasons for termination of tenancy, former landlords, education, accidents, licensure, credit, etc. I further

understand that such reports may contain public record information such as, but not limited to: my driving

record, judgments, bankruptcy proceedings, evictions, criminal records, fingerprint records etc., from federal,

state, and other agencies that maintain such records.

I understand the end-user can use this disclosure in connection to obtaining consumer reports throughout my

employment, volunteer services, contracted service, tenancy, enrollment, etc. with the end-user.

Signature: ________________________________________ Date: ________________________________

Last Revised July 26, 2019



Human Resources


AUTHORIZATION FOR CONSUMER REPORTS


I hereby authorize procurement of consumer report(s) by Champaign Unit 4 (“end-user”). In

connection with the end-user, this authorization shall remain on file and shall serve as ongoing

authorization for end-user to procure such reports at any time during my employment, contract,

volunteer period, student observing/teaching, or other affiliation to the end-user. I authorize without

reservation, any person, business or agency contacted by the consumer reporting agency to furnish the

above-mentioned information.

This authorization is conditioned upon the following representations of my rights:

I understand that I have the right to make a request to the consumer reporting agency: (“Agency”), Bushue

Background Screening, 302 E. Jefferson Avenue, Effingham, IL 62401, telephone number (217) 342-3042,

upon proper identification, to obtain copies of any reports furnished to end-user by the Agency and to request

the nature and substance of all information in its files on me at the time of my request, including the sources

of information, and the Agency, on end-user’s behalf, will provide a complete and accurate disclosure of the

nature and scope of the investigation covered by any investigative consumer report(s). The Agency will also

disclose the recipients of any such reports on me which the Agency has previously furnished within the two

year period for employment requests, and one year for other purposes preceding my request (California three

years). I hereby consent to end-user obtaining the above information from the Agency. I understand that I

can dispute, at any time, any information that is inaccurate in any type of report with the Agency. I may

view the Agency’s privacy policy at their website: www.bushuebackgroundscreening.com.

I understand that I have rights under the Fair Credit Reporting Act, and I acknowledge receipt of the

Summary of Rights _____________ (initials).

I authorize end-user and Agency to use email communication with me to provide me with notices and

information regarding any report or use of such report.

Signature: ________________________________________ Date: ________________________________


http://www.bushuebackgroundscreening.com/



Human Resources


Champaign Unit 4

(BHR Screen)

*Information below is being used for background screening purposes only.

APPLICANT INFORMATION (PLEASE PRINT LEGIBLY)

Applicant’s

Legal Name

(full name)

First: Middle: Last:

Alias or

Maiden Name


Home

Address:

Street Address: City: State: Zip:

Date of Birth:

____ ____ / ____ ____ / ____ ____ ____ ____

Social Security Number:

_____ _____ ______ - _____ _____ - _____ _____ _____ _____

Phone Number: Email Address:

Driver’s License Number:

State of Issuance: Name as it Appears on Driver’s License:

Eye Color: Hair Color: Race: Weight: Height:

______ ft. ______in.

APPLICANT SIGNATURE AND DATE

Signature (parent/guardian signature required if under the age of 18): Date:


1

Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la

Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

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 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 20552.

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:

o a person has taken adverse action against you because of information in your

credit report;

o you are the victim of identity theft and place a fraud alert in your file;

o your file contains inaccurate information as a result of fraud;

o you are on public assistance;

o 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

http://www.consumerfinance.gov/learnmore



2

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 form the lists these offers are based on. You may opt out with the

nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

The following FCRA right applies with respect to nationwide consumer reporting

agencies:

CONSUMERS HAVE THE RIGHT TO OBTAIN A SECURITY FREEZE

You have a right to place a “security freeze” on your credit report, which will

prohibit a consumer reporting agency from releasing information in your credit

report without your express authorization. The security freeze is designed to prevent

credit, loans, and services from being approved in your name without your consent.

However, you should be aware that using a security freeze to take control over who gets

access to the personal and financial information in your credit report may delay, interfere

with, or prohibit the timely approval of any subsequent request or application you make

regarding a new loan, credit, mortgage, or any other account involving the extension of

credit.

As an alternative to a security freeze, you have the right to place an initial or extended

fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is



3

placed on a consumer’s credit file. Upon seeing a fraud alert display on a consumer’s

credit file, a business is required to take steps to verify the consumer’s identity before

extending new credit. If you are a victim of identity theft, you are entitled to an extended

fraud alert, which is a fraud alert lasting 7 years.

A security freeze does not apply to a person or entity, or its affiliates, or collection

agencies acting on behalf of the person or entity, with which you have an existing

account that requests information in your credit report for the purposes of reviewing or

collecting the account. Reviewing the account includes activities related to account

maintenance, monitoring, credit line increases, and account upgrades and enhancements.

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:


4

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 CFPB:

a. Consumer Financial Protection Bureau

1700 G Street, N.W.

Washington, DC 20552

b. Federal Trade Commission

Consumer Response Center

600 Pennsylvania Avenue, N.W.


(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 Financial Protection (OCFP)

Division of Consumer Compliance Policy and Outreach

1775 Duke Street

Alexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings

Aviation Consumer Protection Division

Department of Transportation 1200 New Jersey Avenue, S.E.


4. Creditors Subject to the Surface Transportation Board Office of Proceedings, Surface Transportation Board

Department of Transportation

395 E Street, S.W.


5. Creditors Subject to the Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor

6. Small Business Investment Companies Associate Deputy Administrator for Capital Access

United States Small Business Administration

409 Third Street, S.W., Suite 8200


7. Brokers and Dealers Securities and Exchange Commission 100 F Street, N.E.


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

Federal Trade Commission

Consumer Response Center

600 Pennsylvania Avenue, N.W.


(877) 382-4357



Human Resources


College/University Student-Teacher Paperwork Requirements The following forms must be completed before you can begin your Student-Teaching placement in

Champaign Unit 4 Schools. Completed forms can be turned in at the front desk of the Unit 4 Administrative

Center (located at 502 West Windsor Road in Champaign).

1. Student-Teacher and Student Observer* Information Sheet & Acknowledgements

This form provides the District with general information about you and your placement and helps

you better understand the expectations we have for you during your time in our buildings.

This fully completed form should be turned in along with Item #2. The District will NOT conduct

a background check without the Information Sheet & Acknowledgements on file.

2. Fingerprint-Based Criminal Background Check

All Student-Teachers must successfully complete a fingerprint-based criminal background check

prior to beginning their field experiences. Please contact the Unit 4 Fingerprint Technician at (217)

351-3805 during normal business hours to set up your fingerprinting appointment. When you come

for your appointment, you will need to bring the following with you:

The cost of this background check is $36, which must be paid in cash or check.

One form of photo ID, preferably a Driver’s License, State ID card, or Passport.

Completed Fingerprint-Based Records Check Information and Privacy Act Statement forms

(included in this packet).

A completed State of Illinois Department of Children and Family Services Authorization for

Background Check form (included in this packet).

Fingerprint background check results are usually back within 10 working days, but can take up to 1

month. Please schedule accordingly.

Once you have cleared your background check, you will receive a clearance email from our

Fingerprint Technician. This email serves as your final authorization to begin your placement in our

buildings. It should be provided to your Cooperating Teacher(s) on or before the date your

placement begins. You will not be permitted to begin Student-Teaching without it!

(Note: If you have not received a clearance email one week before your scheduled start date, please

call our office to inquire on your status.)

*Colleges and universities use a variety of terms to identify students engaged in preliminary level “hands on”

work in schools as part of a licensure program. Champaign Unit 4 Schools groups all Field-based,

Practicum, Doctoral, Pre-Clinical, Clinical, and Nursing placements under the “Student Observer” heading.

College/University students who are doing “full takeover” work are considered Student-Teachers.


CHAMPAIGN COMMUNITY UNIT SCHOOL DISTRICT NO. 4 CHAMPAIGN, ILLINOIS

Student-Teacher and Student Observer* Information Sheet & Acknowledgements

* Colleges and universities use a variety of terms to identify students engaged in preliminary level “hands on” work in schools as part of a licensure program. Champaign Unit 4 Schools groups all Field-based, Practicum, Doctoral, Pre-Clinical, Clinical, and Nursing placements under the “Student Observer” heading. College/University students who are doing “full takeover” work are considered Student-Teachers.

Personal Information Last Name First Name Middle Initial Email Address

Present Street Address

City State Zip Phone

( )

Gender

Race/Ethnicity

African American American Indian/Alaskan Hispanic White Asian/Pacific Islander Multi-Racial

College/University Information Unit 4 Placement Information

Placement Start Date

__________________________

Placement End Date

__________________________

Cooperating College/University

____________________________________

College/University Contact Name/Email

____________________________________

____________________________________

Cooperating Unit 4 Teacher(s)

____________________________________

Assigned Unit 4 Building(s)

____________________________________

Grade Level(s)/Subject(s)

____________________________________

Have you previously been placed as a Student-Teacher or Student-Observer in Champaign Unit 4 Schools? (check all that apply) Yes, as a Student Observer Yes, as a Student-Teacher No

In which capacity will you be visiting Unit 4 Schools (see definitions above)? Student Observer* Student-Teacher

Are you interested in receiving information via email from the Champaign Unit 4 Schools Human Resources Department regarding professional networking and professional growth opportunities, along with information about District vacancies? Yes No

Background Information (You Are Not Obligated To Disclose Sealed Or Expunged Records Of Conviction Or Arrest) Have you ever been convicted of any misdemeanor (excluding traffic violations)? If yes, explain. Attach additional sheets, if necessary.

Yes No

Have you ever been convicted of any felony? If yes, explain. Attach additional sheets, if necessary.

Yes No

Have you ever had an indicated finding of child abuse in your name? If yes, explain. Attach additional sheets, if necessary.

Yes No

Mandated Reporter Information

Champaign Unit 4 Schools considers Student Observers and Student Teachers mandated reporters of child abuse and neglect. More information about mandated reporting and training materials can be found at https://mr.dcfstraining.org. By checking the box to the right, you acknowledge that you are expected to report suspected child abuse and neglect. (Please note that your college or university may require additional documentation regarding mandated reporting.)

I understand that I am expected

to report child abuse/neglect.

https://mr.dcfstraining.org/

District Expectations for Student-Teachers and Student Observers* The following are some general expectations the District has for all Student-Teachers and Student Observers*. In addition to the expectations below, Student-Teachers and Student Observers* are expected to abide by all Federal, State, and local laws, as well as the policies and procedures of the Board of Education of Champaign Unit 4 Schools. Additionally, Student-Teachers and Student Observers* are expected to comply with directives from Administration and their Cooperating Teachers. The authority of school personnel, rules, and guidelines should be supported and followed at all times. Any questions, concerns, or observations regarding any rule or guideline may be taken professionally and privately to your Cooperating Teacher or Administrator. Signing In and Out Student Observers* are expected to sign in and out every time they visit a Unit 4 building. There is a section of our official Volunteer Log Book at each campus designated for you to do so. Student-Teachers are not required to sign in and out daily unless directed to do so by their Cooperating Teacher or Administrator. Report Time & Attire If you are unable to be on campus when your Cooperating Teacher or Administrator is expecting you, you should let them know in advance (to the extent possible). Attire must be appropriate for a professional educational environment. Seek guidance from your Cooperating Teacher or Administrator. Interacting with Students All interactions with students will take place on school grounds within view of school personnel or in a room with an open door or within view of a door’s window. Off campus contact is prohibited (including telephone or computer-based interaction), unless specifically authorized by the Cooperating Teacher or Administrator. Your personal contact information should not be shared with any student. Physical Contact Physical contact with the students will be limited, professional, and age appropriate for the child. Remember that what is intended to be simple, friendly affection may be perceived as something entirely different by the student or an observer. If a child persists in being inappropriately physical, please seek the assistance of a staff member immediately. Transportation Transporting a student in a personal vehicle is prohibited. Students must be transported in a District vehicle (field trips), in a school official’s vehicle, or in a parent or legal guardian’s vehicle. Student-Teachers and Student Observers* should not be alone with any student in any vehicle. Confidentiality All things regarding a student and his/her family which are heard or seen at school are confidential and should not be discussed outside of the school environment. They should only be discussed within the school environment when educationally necessary. All confidential information is protected by FERPA (the Family Educational Rights and Privacy Act). Sharing information with others is a violation of the law; however, if a student confides that he or she is the victim of abuse, is considering homicide or suicide, is being bullied or is bullying others, or is involved in any illegal activity, a school official MUST be notified immediately! (Check with your Cooperating Teacher or Administrator if you are unsure to whom to report this information.) It is wise to write down the information, including the date and to whom the information was reported. Remember, this information is extremely personal and capable of damaging lives, so do not share it with anyone except the appropriate school personnel. Please note that reporting information to your Cooperating Teacher or Administrator is separate from the expectation that you report required information to the Department of Children and Family Services (DCFS) as a Mandated Reporter. Important District Policies

Drug-Free Workplace Policy: No person shall unlawfully possess, use, dispense, distribute or manufacture any controlled substance in the workplace.

Use of Tobacco: The use of tobacco in any form is prohibited on all District property.

Sexual Harassment: It is the policy of the Board of Education that sexual harassment of students/employees of the district shall not be permitted. This includes unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature that substantially interfere with work performance or create an intimidating, hostile, or offensive work environment.

I have read this document completely and understand all the information contained in it. I certify that the facts contained in this form are true and complete. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for removal from Student Observation or Student-Teaching, no matter when discovered by Champaign Community Unit School District No. 4. Signature of Student-Teacher/Student Observer*: _________________________________________________ Date: ________________________

FOR OFFICE USE ONLY

Notes:

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________




Human Resources


Privacy Act Statement


Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is

generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental

authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders,

and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure

to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be

predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics

may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the

purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification

(NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other

available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your

fingerprints and associated information/biometrics in NGI after the completion of this application and, while

retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained

by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and

associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your

consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all

applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses

for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to,

disclosures to: employing, governmental or authorized nongovernmental agencies responsible for

employment, contracting, licensing, security clearances, and other suitability determinations; local, state,

tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national

security or public safety.

By signing below, I acknowledge and hereby authorize the release of any criminal history record information

that may exist regarding me from any agency, organization, institution, or entity having such information on

file. I am aware and understand that my fingerprints may be retained and will be used to check the criminal

history record information files of the Illinois State Police and/or the Federal Bureau of Investigation, to

include but not limited to civil, criminal and latent fingerprint databases. I also understand that if my photo

was taken, my photo may be shared only for employment or licensing purposes. I further understand that I

have the right to challenge any information disseminated from these criminal justice agencies regarding me

that may be inaccurate or incomplete pursuant to Title 28 Code of Federal Regulation 16.34 and Chapter 20

ILCS 2630/7 of the Criminal Identification Act.

Signature: ________________________________________ Date: ________________________________




Human Resources


Fingerprint-Based Records Check Information This information is being used for background screening purposes only.

PLEASE PRINT LEGIBLY

Applicant’s Full

Legal Name


Alias or Maiden

Name


Home Address Street Address: City: State: Zip:

APPLICANT INFORMATION

Date of Birth (MM/DD/YYYY):

___ ___ / ___ ___ / ___ ___ ___ ___

Social Security Number:

___ ___ ___ - ___ ___ - ___ ___ ___ ___

Place of Birth (state):

Phone Number: Email Address:

Driver’s License Number:

State of Issuance: Gender:

Male Female

Race (Circle):

Indian/Alaskan

Asian

Black

Pacific Islander

White/Caucasian

Hispanic/Latino

Unknown/Other

Skin Tone (Circle):

Black

Dark Brown

Light Brown

Fair

Light

Medium

Olive

Eye Color (Circle):

Black

Blue

Brown

Green

Gray

Hazel

Other

Hair Color (Circle):

Bald

Black

Blonde

Brown

Gray

Sandy

Red

Height:

______ ft. _______in.

Weight:

CONTRACTORS ONLY

Employer Name: ________________________________

Contact Name: ________________________________ Contact Number: ________________________________

APPLICANT SIGNATURE AND DATE

Signature (parent/guardian signature required if under the age of 18):

Date:

Office Use Only

Proof of Identity:

DL State ID Passport Birth Certificate SSC

ORI Number:

Regular: IL010004S School Bus: SB0100004

Verify Account Code

XCMPU4

Reference Number: TCN:

LS10374L4954

Technician:

Date of Fingerprint: Time: Payment Amount:

Payment Type: Cash Check


CFS 689 Rev 7/2012 State of Illinois

Department of Children and Family Services

AUTHORIZATION FOR BACKGROUND CHECK Child Abuse and Neglect Tracking System (CANTS)

For Programs NOT Licensed by DCFS

NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a licensed child care facility. Please contact your licensing representative.

Name: Last First Middle

Race: Male FemaleGender:

Current Address: Street/Apt #

City State Zip Code

If you currently reside in Illinois, please list all previous addresses for the past five years. OR

If you currently reside out-of-state, please provide ALL Illinois addresses in which you did reside while living in Illinois.Dates

(Street/Apt#/City/County/State/Zip Code) From/To

List maiden name and/or all other names by which you have been known: (last, first, middle)

I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child Abuse and Neglect Tracking system (CANTS) to determine whether I have been a perpetrator of an indicated incident of child abuse and/or neglect or involved in a pending investigation. I further consent to the release of this information to the agency listed below.

Signed Date

Please type, use bold letters or label:

(Agency Name)

(Contact Person)

(Address)

(City/State/Zip)

FAX to: 217-782-3991Scan/Email to: [email protected]

Submit by mail OR fax OR email.Mail to: Department of Children and Family Services

406 E. Monroe – Station # 30 Springfield, IL 62701

(Submitting Agency Fax Number) (Submitting Email Address)

Date of Birth: -- --

administrative center human resources

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