UCI Employment Misconduct Disclosure Questionnaire and Authorization of Information Release

UCI Employment Misconduct Disclosure Questionnaire and Authorization of Information Release

Required as a condition of academic employment.
The UC is committed to maintaining, building, and supporting an inclusive, healthy, and safe work environment for all to thrive in. To that end, it has pre-employment processes that gathers information about current or past conduct that may impact a workplace or its members. Within its review, the University will aim to determine whether such conduct has an impact on an individual’s ability to perform the underlying duties associated with their proposed employment at UC.

Disclosure of misconduct does not automatically disqualify an applicant from consideration for employment. Information provided through this questionnaire will be evaluated as part of the University's overall assessment of the applicant's suitability for the position.

The submission of this form indicates that you have been informed by the University that you are under serious consideration for work opportunities at UCI. All information received is treated confidentially and will be subject to applicable retention policies. UCI wants to make sure that you understand the questions found on this form. If you are unsure about the meaning of any of the questions or the definitions found below, please reach out to your academic and/or hiring department. Should you require further assistance, please contact aprefcheck@uci.edu.

Note: This form page is reserved for graduate students under consideration for employment opportunities at UCI only. If this description does not apply to you, please DO NOT complete this form. You can instead complete your submission here: https://form.jotform.com/UCIAcademicPersonnel/misconductdisclosureandrelease. Thank you.

Definitions

For purposes of this questionnaire, the following definitions apply:

Misconduct:
- Any violation of the policies or laws governing conduct at the applicant’s previous place of employment, including, but not limited to, violations of policies or laws prohibiting sexual harassment, sexual assault, or other forms of harassment or discrimination, as defined by the employer.
Decisions include:
- Final Administrative Decision is a final written determination by a previous employer as to whether a candidate has committed Misconduct. Examples of a final administration decision include but are not limited to, a determination by a decisionmaker (employer or state or federal agency) following a final investigative report and the subsequent hearing, or the imposition of employment discipline or corrective action related to the candidate’s Misconduct. If an applicant has filed a timely grievance or Appeal, a decision is considered final only after the grievance or Appeal process has concluded.
- Final Judicial Decision is a final determination of a matter submitted to a court regarding the candidate’s Misconduct that is recorded in a judgment or order of that court.
Appeal is defined as:
- A request for a review of a Final Administrative Decision or Final Judicial Decision (“Decision”) through an employer, administrative agency, court, or other authorized review process. Examples include filing a grievance, using an appeal process defined by policy, or filing an appeal with the appropriate judicial body or agency.
Applicant Information
Name:

First NameMiddle InitialLast Name
Email:
example@example.com
UCI Student ID Number:
Academic School:
Enter the academic school you are admitted to and are primarily affiliated with at UCI to allow us to best identify you.
Academic Department:
Enter the academic department you are admitted to and are primarily affiliated with at UCI to allow us to best identify you.
Hiring School:
Enter the hiring school you plan to work for. (If unsure, enter the academic school you are admitted to and are primarily affiliated with at UCI to allow us to best identify you).
Hiring Department:
Enter the hiring department you plan to work for. (If unsure, enter the academic department you are admitted to and are primarily affiliated with at UCI to allow us to best identify you).
Most Recent Employer (e.g. University or Company Name):
CPO Email:
example@example.com
Hiring CPO Email:
example@example.com
Disclosure Questionnaire
1. Has a Final Administrative/Judicial Decision(s) been issued within the last seven years from the date of submission of your application determining that you committed Misconduct?
Name of employer, administrative agency, or court (please include location and division/department):
When did the misconduct occur?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
When did you receive the Decision(s)determining you committed the misconduct?

MonthDayYear
2 digit month, 2 digit day, 4 digit year
What was the misconduct?
What circumstances or factors contributed to the occurrence of the misconduct?
Did the Misconduct involve an abuse of power and authority, such as involvement of subordinate employees, students, or minors?
Please provide more detail about your relationship to the involved parties. Do not include names of individuals.
Did the Decision(s) result in discipline or did it include a recommendation for the imposition of Discipline?
What was the recommended and/or imposed discipline?
Did the employer require other follow-up action such as counseling, training, and/or implement a performance improvement plan related to your behavior?
What was the action? What did you learn and what changes, if any, have you made as a result?
Was your employment terminated due to the misconduct?
Date of Separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2. Have you filed an appeal in court regarding a Final Judicial Decision?
Which court did you file your appeal with?
What is the basis for appeal?
Date(s) of filing the appeal?
When do you anticipate being informed about a decision on the appeal?

Authorization of Information Release
This form authorizes your current and previous employers to provide the University of California with information regarding any Substantiated Allegations of Misconduct, as permitted by California Education Code Sections 92612.1 and 92612.2.

The purpose of this authorization is to permit the University of California to obtain and evaluate such information for employment.

For purposes of this Authorization, Substantiated Allegations means an allegation that has been sustained based upon a burden of proof of at least a preponderance of the evidence. Misconduct means any violation of the policies governing conduct at an applicant’s previous place of employment, including, but not limited to, violations of policies prohibiting sexual harassment, sexual assault, or other forms of harassment or discrimination, as defined by the previous employer.

Authorization
By signing this form, I authorize the responsible office(s) at my current or prior institution(s) where I have been employed, to release information to the University of California related to any Substantiated Allegations of Misconduct (including sexual harassment) policy violations attributed to me.

This authorization includes release of information of a confidential or privileged nature, or any data or materials which have been sealed or agreed to be withheld pursuant to any prior agreement or court proceeding, involving disciplinary matters.

Should an institution provide information on an incident of misconduct, I will be informed and allowed to provide information in response.

Submission of this form does not necessarily mean that my current employer will be contacted immediately. Campuses will determine the timing of contacts with previous employer(s) in accordance with APM - 500 and local implementation procedures.
The following are other name(s) that appear on my personnel and/or academic records at my current or prior locations of employment, which may differ from the name that I have provided to the University of California:
I hereby release, discharge, and exonerate (1) the University of California, its agents and representatives and (2) any institution or employer where I am currently, or have in the past been, employed, or any individual acting on behalf of such institution or employer, furnishing information to the University of California, from any and all liability of every nature and kind arising out of the furnishing and inspection of such documents, records and other information.This release shall be binding on my legal representatives and successors.
Signature
This authorization is valid for 365 calendar days from the date of signature. A photocopy, digital signature or PDF of this release is to be considered as valid as an original.
Should be Empty:

UCI Employment Misconduct Disclosure Questionnaire and Authorization of Information Release

Applicant Information

Disclosure Questionnaire

Authorization of Information Release