3 CCR 716-1-A - 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 section 12-30-115, C.R.S., and the rules promulgated pursuant to this statute by the relevant regulator. 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 section 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. Pursuant to section 12-30-115, C.R.S., and the rules promulgated pursuant to this statute by the relevant regulator, a listing of any final convictions of or acceptances of guilty pleas by a court for a sex offense, as defined in section 16-11.7-102(3), C.R.S.
C. For each, the provider shall provide, at a minimum:
1. The date that the final judgment of conviction or acceptance of a 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 per issued an order approving the guilty plea.
D. Pursuant to section 12-30-115, C.R.S., and the rules promulgated pursuant to this statute by the relevant regulator, a listing of any final agency action by a regulator that results in probationary status or other limitation on the provider's ability to practice, when the action is based in whole or in part on:
1. a conviction or acceptance of a guilty plea by a court for a sex offense, as defined in section 16-11.7-102(3), C.R.S., or a finding 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 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, 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 regulator 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;
3. The date the final agency action was issued;
4. The date the probation status or practice limitation ends; and
5. The contact information for the regulator 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 Patient Name
_______________________________________________________________
Patient or Responsible Party's Signature Date
If signed by Responsible Party (parent, legal guardian, or custodian), print Responsible Party's name and relationship to patient:
_______________________________________________________________
Print Responsible Party Name Print Relationship to Patient
_______________________________________________________________
Provider Signature Date
Notes
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