EMPLOYEE INFORMATION RELEASE FORM
Under Nebraska state statutes, a current or former employer may disclose the
following information about a current or former employee’s employment history
to a prospective employer of the current or former employee upon receipt of
written consent from the current or former employee:
· Date and duration of employment;
· Pay rate and wage history on the date of receipt of written consent;
· Job description and duties;
· The most recent written performance evaluation prepared prior to the date of the request and provided to the employee during the course of his or her employment;
· Attendance information;
· Results of drug or alcohol tests administered within one year prior to the request;
· Threats of violence, harassing acts, or threatening behavior related to the workplace or directed at another employee;
· Whether the employee was voluntarily or involuntarily separated from employment and the reasons for the separation; and
· Whether the employee is eligible for rehire.
I, _______________________, hereby give consent to any and all prior employers of mine to provide information in accordance with state statutes with regard to my employment with prior employers to the following prospective employer: _____________________________________________________________.
I realize that by disclosing such information the employer shall be presumed to be acting in good faith and shall be immune from civil liability for the disclosure or any consequences of such disclosure to the extent provided by state statutes. I understand that even with receipt of this form the district may, at the superintendent’s discretion, refuse to release such information.
(Signature of Current or Former Employee) (Date)
THIS FORM BECOMES INVALID SIX MONTHS FROM THE ABOVE DATE
Exhibit COLUMBUS PUBLIC SCHOOLS
Adopted: 8/13/12 Columbus, NE