GBEC-E-2

File: GBEC-E-2

DRUG-FREE WORKPLACE

EMPLOYEE CONVICTION REPORT

By law, this report must be filed with the superintendent of schools within five (5) day following any conviction (including pleas of Guilty) of violating a criminal drug statute arising from workplace conduct. Failure to file this report with the superintendent within five (5) days makes you liable to disciplinary action, up to and including termination.

EMPLOYEE NAME: SCHOOL:

POSITION: DATE HIRED:

I hereby report that I was convicted of, or pleaded guilty to, the following violation of a criminal drug statute arising from workplace conduct. (Describe violation, when and where it happened):

This conviction was entered in the following court at the date shown:

COURT: DATE:

TODAY’S DATE:

I understand that within thirty (30) days of today’s date, the West Springfield School District must either discipline me, including the possibility of termination, or refer me for participation in an authorized rehabilitation or drug abuse counseling/treatment program.. If referred, and accepted by me, I must satisfactorily take part in the program to continue employment in the West Springfield School District. My preference of action is (please check one):

DISCIPLINARY ACTION REHABILITATION PROGRAM

SIGNATURE: DATE:

PRINT NAME:

NOTE: Title updated to reflect title change in policy (File: GBEC) 8/30/16