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.

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 a previous place of employment, including but not limited to, sexual harassment, sexual assault, or other forms of harassment, discrimination, dishonesty or unethical conduct, as defined by a previous employer.
Decisions include:
- Final Administrative Decision: A formal determination made in writing by an official decision maker or office, (such as an employer, state or federal government agency), that concludes a violation of Misconduct was committed by the respondent. Examples include, but are not limited to, findings from an investigative report, the imposition of employment discipline or corrective action, or a documented order/judgement from an administrative hearing or subsequent hearings.
- Final Judicial Decisions: A formal determination, judgement, and/or order issued by a judicial, legislative, or government court that concludes a violation of Misconduct was committed by the respondent.
Appeal is defined as:
- A request for a formal review of a Final Decision with a previous employer or government agency, as defined above. Examples include filing a grievance, using an appeal process defined by a policy or agreement, or filing an appeal with an appropriate judicial body or government 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.
Most Recent Employer (e.g. University or Company Name):*
CPO Email:
example@example.com
Disclosure Questionnaire
1. Has a 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
When did you receive the Decision(s)determining you committed the misconduct?*

MonthDayYear
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?*
Have you filed an Appeal of a Decision after the determination of Misconduct?*
Date(s) of filing the appeal?*
What is the basis for appeal?*
When do you anticipate being informed about a decision on the appeal?*
Was your employment terminated due to the misconduct?*
Date of Separation*

MonthDayYear
Date
2. Have you been given notice of allegation(s) of Misconduct or are you currently the subject of any administrative or disciplinary proceeding involving Misconduct (i.e., informal resolution, alternative resolution,investigation, hearing)? *
Name of employer or administrative agency(please include location and division/department):*
What is the alleged misconduct?*
When did the alleged misconduct occur?*

MonthDayYear
When did you receive notifice?*

MonthDayYear
Have you left a position after receiving a notice of allegation(s) of Misconduct or while you were the subject of any administrative or disciplinary proceeding involving Misconduct (i.e., informal resolution, alternative resolution, investigation, hearing)?*
Why did you leave?*
I am affirming that I have honestly, accurately, and fully answered the questions on this form to the best of my knowledge. I understand that honestly and accurately completing my UC application materials, including the responses on this form, is a condition of employment with UC and that failure to do so may result in serious employment action, up to and including termination.

Template Authorization of Information Release
I authorize the release of information requested by the University of California concerning any misconduct (including Sexual Harassment) attributed to me within the last seven years from my application submission date.

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

This signed release form authorizes the responsible office(s), such as the Academic Personnel Office, Human Resources, or Title IX office at my current or prior institution(s) where I have been employed, to share information related to any misconduct (including Sexual Harassment) policy violations attributed to me with the University of California.

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 a finding of misconduct, I will be informed and allowed to provide information in response.
I hereby release, discharge, and exonerate (1) the University, 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, 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*

Clear
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

Template Authorization of Information Release