Arrest/Conviction Reporting

Arrest/Conviction Report and Certification Form (PDE-6004) 

Act 24 of 2011 and Act 82 of 2012 require school district employees to self-report an arrest by completing the Arrest/Conviction Report and Certification Form (PDE-6004) within seventy-two (72) hours. This completed form must be returned to the Human Resources Department - see form below.

These are consequences listed on the PDE-6004 Form: 

§4904.  Unsworn falsification to authorities.

  •   (a)  In general.--A person commits a misdemeanor of the second degree if, with intent to mislead a public servant in performing his official function, he:

      (1)  makes any written false statement which he does not believe to be true;

      (2)  submits or invites reliance on any writing which he knows to be forged, altered or otherwise lacking in authenticity; or

      (3)  submits or invites reliance on any sample, specimen, map, boundary mark, or other object which he knows to be false.

  •    (b)  Statements "under penalty".--A person commits a misdemeanor of the third   degree if he makes a written false statement which he does not believe to be true,   on or pursuant to a form bearing notice, authorized by law, to the effect that false   statements made therein are punishable.

  •    (c)  Perjury provisions applicable.--Section 4902(c) through (f) of this title (relating   to perjury) applies to this section.

  •    (d)  Penalty.--In addition to any other penalty that may be imposed, a person   convicted under this section shall be sentenced to pay a fine of at least $1,000.

 

Arrest_or_Conviction_form (PDF)