4 CCR 741-1-B - MODEL SEXUAL MISCONDUCT DISCLOSURE STATEMENT
DISCLAIMER: This Model Sexual Misconduct Disclosure Statement is to be used as a guide only and is aimed only to assist the practitioner in complying with § 12-30-115, C.R.S., and the rules promulgated pursuant to this statute by the Director. As a licensed, registered, and/or certified health care provider in the State of Colorado, you are responsible for ensuring that you are in compliance with state statutes and rules. While the information below must be included in your Sexual Misconduct Disclosure Statement pursuant to § 12-30-115, C.R.S., you are welcome to include additional information that specifically applies to your situation and practice.
A. Provider information, including, at a minimum: name, business address, and business telephone number.
B. A listing of any final convictions of or a guilty plea to a sex offense, as defined in § 16-11.7-102(3), C.R.S.
C. For each such conviction or guilty plea, the provider shall provide, at a minimum:
1. The date that the final judgment of conviction or guilty plea was entered;
2. The nature of the offense or conduct that led to the final conviction or guilty plea;
3. The type, scope, and duration of the sentence or other penalty imposed, including whether:
a. The provider entered a guilty plea or was convicted pursuant to a criminal adjudication;
b. The provider was placed on probation and, if so, the duration and terms of the probation and the date the probation ends; and,
c. The jurisdiction that imposed the final conviction or issued an order approving the guilty plea.]
D. A listing of any final agency action by a professional regulatory board or agency that results in probationary status or other limitation on the provider's ability to practice if the final agency action is based in whole or in part on:
1. a conviction for or a guilty plea to a sex offense, as defined in section 16-11.7-102(3), C.R.S., or a finding by the professional regulatory board or Director that the provider committed a sex offense, as defined in as defined in section 16-11.7-102(3), C.R.S.; OR
2. a finding by a professional regulatory board or agency that the provider engaged in unprofessional conduct or other conduct that is grounds for discipline under the part or article of Title 12 of the Colorado Revised Statutes that regulates the provider's profession, where the failure or conduct is related to, includes, or involves sexual misconduct that results in harm to a patient or presents a significant risk of public harm to patients..
E. For each such final agency action by a professional regulatory board or agency the provider shall provide, at a minimum:
1. The type, scope, and duration of the agency action imposed, including whether:
a. the regulator and provider entered into a stipulation;
b. the agency action resulted from an adjudicated decision;
c. the provider was placed on probation and, if so, the duration and terms of probation; and
d. the professional regulatory board or agency imposed any limitations on the provider's practice and, if so, a description of the specific limitations and the duration of the limitations.
2. The nature of the offense or conduct, including the grounds for probation or practice limitations specified in the final agency action;
a. The date the final agency action was issued
b. The date the probation status or practice limitation ends; and
c. The contact information for the professional regulatory board or agency that imposed the final agency action on the provider, including information on how to file a complaint.
Sample Signature Block
I have received and read the sexual misconduct disclosure by [Provider Name] and I agree to treatment by [Provider Name].
_______________________________________________________________
Print Client Name
_______________________________________________________________
Client or Responsible Party's Signature Date
If signed by Responsible Party (parent, legal guardian, or custodian), print Responsible Party's name and relationship to client:
_______________________________________________________________
Print Responsible Party Name Print Relationship to Client
_______________________________________________________________
Provider Signature Date
_________________________________________________________________________
Notes
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