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:

_______________________________________________________________________ 

________________________________________________________________________ 

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Revised 7/30/03