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UNITED
TEACHERS OF DADE
CONFERENCE-FOR-THE-RECORD SUMMARY FORM
Instructions: Please print legibly and
retain for your records for 3 years.
Your Name ___________________________________
Date of CFR:_______________
Employee Name: __________________________________
Employee #:____________
Work Location: _________________________ Work Location
Phone:_______________
Employee Home Phone:_______________ Contract Status: ___
Annual ___ PSC ___ CC
Non-Instructional: ___ Para/ESP
___ Security Monitor ___
Full Time Office Personnel
CFR Notification Attached: ___ YES ___ NO
Date Notification Issued:______________
From Whom: _________________________
Title: _____________________________
Purpose of the CFR as Indicated in Notification:
________________________________________________________________________
________________________________________________________________________
Date(s) of Alleged Infraction: __________________ Case #
(s): __________________
Start Time: _________________________
End Time: __________________________
Name and Title of Individuals Present:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Issues Raised by Administration:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Response- Expanation(s) Offered or Concern(s) Raised by
Member Union Building Steward/ Union Representative:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Conclusions/Recommendations/Directives/Actions (e.g.
PACES Domain VII, Reprimand) by Administration
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Agreements Reached:
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Pending Requests/Materials/Responses:
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other Agencies Involved: (e.g. School Police, Office of
Professional Standards, DOE, Certification, Professional Practices
Commission):
_______________________________________________________________________
________________________________________________________________________
Additional Comments:
_______________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
________________________________________________________________________
Revised 7/30/03
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