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Staff Self-Reporting of Arrests, Criminal Charges, and Convictions


About this Form

Form number: 230-41

Audience:  MCPS Staff

Last revised: July 2017

INSTRUCTIONS: Any person employed by MCPS in any capacity (including but not limited to full- or part-time, probationary or non-probationary, employed in a temporary or seasonal capacity, or substitute teachers) shall report an arrest or criminal charge for any of the offenses listed on this form as well as the disposition of any ensuing criminal proceeding, which occur on or after October 1, 2016, to the Department of Compliance and Investigations (DCI), within the Office of Employee Engagement and Labor Relations (OEELR), within seven business days of such arrest or criminal charge (i.e., days that MCPS offices are open), except in circumstances beyond the employee’s control. Self-reporting must occur regardless of where the alleged criminal activity occurred and whether or not it was within the scope of the employee’s job duties. Self-reporting a charge or an arrest will not be considered or treated as an admission of guilt. After completion of this form, submit it to

See MCPS Regulation GCC-RA, Staff Self-Reporting of Arrests, Criminal Charges, and Convictions for definitions of arrest, criminal charge, conviction, disposition, and self-reporting.

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