Scott A. Gaines Dr. Christopher J. Marczak Asstant Superintendent of instruction ‘Superhtendent of Schools Stan J. Breeden Maury County Public Schools ‘satiot Spcwemt cf pene 501 West 8" Street, Columbia, TN 38401 (931) 388-8403, Fax (931) 840-4410 March 14, 2017 Mr. Tad Cummins Dear Mr. Cummins, This is official notice that you are terminated from your position with Maury County Public Schools. You should surrender to the Central Office all items in your possession that are the property of Maury County Public Schools, including your MCPS employee badge. Enclosed with this letter are charges for your dismissal. You have the right to appeal this decision in accordance with MCPS Policy 5.201. You must send written notice of your intent to make such an appeal to my attention within ten (10) calendar days of the date of this letter Any questions concerning this termination may be directed to Amanda Hargrove, Chief of Staff, at 931- 388-8403 ext. 8117, Dr. Christopher. Superiftendent ezak Sfhools Ce: Personnel file Payroll DepartmentCHARGES FOR DISMISSAL. Tad Cummins is a non-tenured teacher assigned to Culleoka Unit School. Specific charges for dismissal are made as follows: CHARGE! Mr. Cummins has conducted himself in an unprofessional manner during his employment with the District. The evidence obtained by the District supports a conclusion that Mr. Cummins has engaged in and/or created the appearance of engaging in an inappropriate relationship with a student. CHARGE Il Mr. Cummins has been insubordinate to his direct supervisors as evidenced by his willful disregard of their expressed and implied directions and refusing to obey reasonable orders. Specifically, the evidence obtained by the District indicates that Mr. Cummins failed to follow instructions from his immediate supervisor, and failed to follow District policies and procedures related to contact with students. ‘The charges and specifications set forth above constitute the following offenses: -Unprofessional Conduct; and - Insubordination. Upon these grounds as Superintendent of Schools, | hereby dismiss Tad Cummins from employment as a teacher with Maury County Public Schools.STATE OF TENNESSEE STATE BOARD OF EDUCATION 815-741-2966 wwnwstate.tn.us/sbe Final Report Regarding Teacher/Administrator with Flagged License Submit to: Office of Teacher Licensing State Department of Education 4® Floor, 710 James Robertson Parkway Nashville, TN 37243 FAX: 615-532-1448 Date of Acti 3-14-2017 LEA submitting Report: Yaury Coun ty Name of Teacher/Administrator: _“Jaal_Cummains ‘Teacher/ Administrator License #: ———_h known add = Final LEA employment action: termination Status of investigations): -DCS: - Law enforcement (agency): on-going | Further information may be obtained from dinclude contact information): Aman Haren e__alevardera 1@ maury kigerg 151 BEF S403 ed. 81 en : ogy Flb-2017 Director Signature} [Date] ‘hte Bost of Bduston Rey. B, Nov, 2006Scott A. Gaines Dr. Christopher J. Marczak Asst Sete of 08 Superintendent ‘Stan J, Breeden Maury County Public Schools scxricetinanammmiets mm! ‘501 Wests" Street, Columbia, TN 38401 (@31) 388-8403, February 6, 2017 ‘Mr. Tad Cummins HAND DELIVERED ce Dear Mr. Cummins, ‘This letter is official notification that you are hereby suspended from your position with Maury County Public Schools pending an investigetion, You are suspended without pay until further notice, Be aware that this suspension is effective immediately. You should surrender to the Central Office any and all items in your possession that are the property of Maury County Public Schools, including your MCPS employee bafige. ‘You will be notified as to the disposition of this matter. ‘Any questions concerning this suspension may be directed to Amanda Hargrove, Chief of Staff. ‘Amanda may be reached at (931) 388-8403 ext. 8117, Sincerely, Ce: Personnel file Payroll Department Rayeout, Amanda, Muuke, Kenny, Cus, L.Brown Educating every child for LIFE!STATE OF TENNESSEE STATE BOARD OF EDUCATION 615-741-2966, www state.tn.us/sbe Director’s Report Regarding Licensed Teacher/Admii Pursuant to Tennessee State Board of Education Rule 0520-2, 01(9), submit Office of Teacher Licensing State Department of Education 4* Floor, 710 James Robertson Parkway Nashville, TN 37243 FAX: 615-532-1448 Date of Action: -b-IT Name of Teacher/Administrator: “Za _Cunurnns | ——n Teacher/Administrator License: i Last known address and phone number: om, Nature of LEA employment action cin Suspension) Termination | Resignation Following allegations, which, if substantiated, would constitute (circle): 1, Convietion of a felony, 2. Conviction of possession of narcotics, 3. Being on school premises or at a school-related activity involving students while documented as being under the influence of, possessing or consuming alcohol or illegal drugs, 4, Falsification or alteration of a license or documentation required for licensure, - Denial, suspension or revocation of a license or certificate in another jurisdiction for \\ reasons which would justify denial, suspension or revocation under this rule, or } Other good cause, Other good cause shall be construed to include noncompliance / with security guidelines for TCAP or successor tests pursuant to T.C.A. § 49-1-607, default on a student loan pursuant to T.C.A. § 49-5-108(d)(2) or failure to report under part (¢). insubordination State Bourd of Bveaton ev. D, Feb 2007Status of investigation(s): ~ LEA: Closeel -DCS: - Law enforcement (agency): ~ Goin Further information may be obtained from the following people (include contact information, such as phone number and/or email address): 1 Amanda Flarqrove aTerandera 2 pnaunta-or' (i) 38f-F40e J. J 4 omeees bate edul-!1 [Director Signature] [Date] De Chis opher, Mecexak, [Director's Printed Name] : 4 LEA/School Filing Report: Maur 4 Coun y ‘State Board of Edveston Rev. D, Feb 2007CULLEOKA SCHOOL 1921 WARRIOR WAY CULLEOKA, TENNESSEE 38451 931-987-2511 FAX: 931-987:2594 OFFICIAL REPRIMAND SUBJECT: Letter of Reprimand TO: Tad Cummins TITLE: CTE Teacher SCHOOL DEPARTMENT: Culleoka Unit Schoo! In accordance with the provision of Maury County Public Schools’ discipline guidelines, | have determined to issue you a formal OFFICIAL REPRIMAND for the following Employee Code of Conduct violation: INSUBORDINATION ‘The reason(s) for this actions are as follows: ‘* OnJanuary 31, 2017, you were instructed by Principal Penny Love to not allow Mary Catherine Thomas in your classroom. * On January 31, 2017, Mary Catherine Thomas was instructed by Principal Penny Love to not be in your classroom, and to seek counseling from CUS High School Guidance Counselor, Alison Reischman, if needed © On February 3, 2017, Mary Catherine Thomas was in your classroom from 12:11 p.m.-12:44 p.m. «This was a violation of my diréctive to you on Jenuary 31, 2017. As provided with the provision of Maury County Public Schools’ discipline guidelines, this letter will be retained in your Official Personnel File. The occurrence of the same or substantially similar Employee Code of Conduct violation during this timeframe may result in more severe disciplinary action. IF you question the merits of this action, you may seek relief in accordance with Maury County Public ‘School policy. if you desire further explanation of these procedures, you may contact the Supervisor of Human Resources, You ate requested to acknowledge receipt of this letter on the space provided on the attached copy and return itto the undersigned. Your signature merely shows that you have received the letter and does not signify that you agree with its content. Signature of Mdministrator I hereby acknowledge receipt of this letter on February 3, 2017. Employee Signature Cc: Official Personnel FileCULLEOKA SCHOOL 1921 WARRIOR WAY CULLEOKA, TENNESSEE 38451 931-987-2511 PENNY LOVE FAX: 931:987:2594 ‘PRINCIPAL OFFICIAL REPRIMAND. SUBJECT: Letter of Reprimand TO: Tad Cummins TITLE: CTE Teacher SCHOOL DEPARTMENT: Culleaka Unit Schoo! In accordance with the provision of Maury County Public Schools’ discipline guidelines, | have determined to issue you a formal OFFICIAL REPRIMAND for the following Employee Code of Conduct violation: NON PROFESSIONAL CONDUCT (NON-CRIMINAL) The reason(s) for this actions are as follows: Allowing a particular student to spend an excessive amount of time in your classroom creating an unprofessional environment. [As provided with the provision of Maury County Public Schools’ discipline guidelines, this letter will be retained in your Official Personnel File, The occurrence of the same or substantially similar Employee Code of Conduct violation during this timeframe may result in more severe disciplinary action, It you question the merits of this action, you may seek relief in accordance with Maury County Public ‘School policy. If you desire further explanation of these procedures, you may contact the Supervisor of Human Resources. You are requested to acknowledge receipt ofthis letter on the space provided on the attached copy and return itto the undersigned, Your signature merely shows that you have received the letter and does not signify that you agree with its content. Signature of thereby 9. receipt of this letter on February 3, 2017. Employee Signature Ce: Official Personnel FileScott A. Gaines Dr, Christopher J. Marczak scant poten et ‘Superintendent Stan J. Breeden Maury County Public Schools dtr nto Conte ‘501 West & stret, Columbia, TN 38403 (931) 388-8403 ‘January 27,2017 To Whom it May Concern: We request a change to the historical data for Tad Eric Cummins (license number 0005829. ‘We are unable to determine the level of effectiveness score for 2014-15 due to no Growth Measure score. We request that the Growth Measure Score of _2__ be entered. ‘The teacher is aware of this change as indicated by his signature below. ‘Thanks, thf + Scott A. Gaines 1 Tid Lena op am aware of this change to my historical evaluation data, —Z Educating every child for LIFE!Scott A. Gaines Abit pete ea Dr. Christopher J. Marczok eee Stan J, Breeden, Maury County Public Schools ‘eb ectnat toe 501 West &stret, Columbia, 1 38401 (aor) aee-os03 Teacher Contract of Employment 2016-2017 MAURY COUNTY BOARD OF EDUCATION by and through its Superintendent enters into this employment contract with TAD ECUMMINS as a/an [job Tile racatony | [CTE - Heath Science Teacher (CULLEOKA UNIT|S39, 348,00) “Paco ip on by per ed el ly, ple capt Cae Lapp cri ce foc a Bn ays ry ant ae maar ein fae cg ep ep va 1 enn ae lip cay my a A ec ps Bd, es i vse plo Sen Rios aay iy wa ane pay nie, pro ly bat fom ol anes, “Teo et a gsi coun by cnc ea age ic pes a pre uy eb ei py a gay “Tasos mesa ll Teun elt eso Eran eal leaps Many Cay Bae fc. {be stead atta lipo tr ny st a al tat et Septet pon enor st dane ath, Al eat emo an ‘Semmmreconga al a “Tas hl rot tc pit yay Bay Po lan a tae iy pty St ‘Taegu ny eto emia cc ony i a tft oon oa ca elt eon es. “Tense ag ede lary ang ep pu sh A ay aa er eed yo Sep “Tn Spe ype opie ec on ea ey, pe oe _cncein, egos oe ip) smi a nn i at “Tesolin at tig» ence pon, Sa lo spy fond enloat Al pln et pli Coy Bar ft ane yaa i cs, ‘Patna sn ici on en bey Ae amp i al pve te ie ts cee al core vie cosinor ly al oy a pas aaa a 1s enn at ccs eto piss fl ap eile waa fa Gc Ase a Seas se ais fa Ses ‘ACCEPTED: MAURY COUNTY PUBLIC SCHOOLS D2 Aon Ma ar yah ‘Sipeatondent TCA-49.5.408pit & 4 "Scott A, Gaines Dr. Christopher J. Marczak % : Stan Breeden rector of Stools penitent, Maury County Public Schoots Patty Va 501 West 8" Street, Columbia, TN 38401. cca (931) 388-8403, Fax (931) 840-4410 Teacher Contract of Employment 2015-2016 MAURY COUNTY BOARD OF EDUCATION by and through its Director of Schools enters into this employment contract ‘with Tad Cummins as a/an CTE - Health Science Teacher at Culleoka Unit School. This contract is agreed upon by the parties, snd the anal salary, applicable supplements and Carer Taudder payments ae determined according to Local and State salary schedules and The Memorandum of Understanding, Salary amounts may be changed due to error or submission of additional teaching experience and/or degree advancement by January 308 ofthe curent schoo! year Tndestad that Tam obligated fo camy out my duties in accordance with thecal adopted by the Board, unless excused under the provisions of Bond polly or Sate Res and Regulation. fat any time any areas of extra responsibilty are discontinued, that portion of the salary will be deducted from the total amount. ‘The employee understands that the responsibilities covered by this contract, including extra assignments for which supplements are provided, may not be relinquished in part by the employee. ‘The employee agroes to observe and follow all Tennessee laws, all rules and regulations of the State Board of Education, and all rules and regulations of the Maury County Board of Education. Talso understand that Tam obligated to submit my current and valid teacher’s license to the Director's office upon employment ‘or When changes are made, All other employment data and forms must be completed in a timely manner: The employee shall not be entitled to payment of any salary for any pay period until reports due at that time have been timely ‘and properly filed. ‘The Director of Schools reserves the right to terminate this contract if necessary inthe best interest ofthe school system because ofa decrease in enrollment or for other good reasons, ‘The employee agroes to work in any building o» department or perform such duties which may be assigned or required by the Director of Schools. ‘The Director of Schools may temporarily suspend this contract when deemed necessary, pending investigation Incase of resignation, the employee agrees to give the Director of Schools thirty (30) days’ notice aud to continue in service ‘until such time has transpired; provided that earlier termination may be made by mutual written consent of both parties, ‘The employee understands that if filling a temporary/interim position, there is no expectancy of continued employment. All policies and the policy manual of Maury County Board of Education are incorporated by reference into this contract. "The clauses, sentences and parts of this contract are severable to the extent found to be unlawful or ineffective by a court of competent jurisdiction and if so held, the remaining provisions of the contract shall remain in full force and effect. ‘Nothing in this contract shall be construed to provide future or continued employment unless specifically agreed to by the parties ina separate agreement, It is understood that this contract is subject tothe provisions of all applicable legislative enactments of the General Assembly of the State of Tennessee and rules and regulations of the State Board of Education ACCEPTED: MAURY COUNTY PUBLIC SCHOOLS Sh a Blo iffy Patin Mong he Z — YDS QO swans ‘Teacher's Signature rate Director of Schools * Date TCA-49-5-408pt, £ % Scott A. Gaines Cynthia Johnson 8 yi Stan Breeden Interim Ditector of Schools: sri ct teste Maury County Public Schools patty Vargo 501 West 8" Street, Columbia, TN 38401 Assistant Bector of France (931) 388-8403, Fax (931) 840-4410 May 15, 2015 Tad Cummins Culleoka Unit School Dear Mr, Cummins: Congratulations! This letter is teacher for the 2015-2016 school year. Thank you for County Public Schools. Respectfully, Crgatddin. G Garanen Cynthia Johnson Interim Director of Schools Ciiéjm C: Principal Personnel file to serve as official notification that you are renewed as @ your continued service to Maury‘Scott A, Gaines Edward A. Hickman Stan Breeden Director of Schoo's psa bce pts Maury County Public Schools Pal 501 West 8” Street, Columbia, TN 38401, sonable ee (931) 388-8403, Fax (931) 840-4410 May 15, 2014 ‘Tad Cummins “ Culleoka Unit Schoo! ‘Dear Mr. Cummins: Congratulations! ‘This letter is to serve as official notification that you are renewed as @ teacher for the 2014-2015 school year. Thank you for your continued service to the Maury County Public School System. Pan Ss AGE ‘Edward A. Hickman Director of Schools BAH/djmEducator Uist ‘Search Again Log Out soeERER J Ueensbae ANEGRNATION Educator Licensure Information Gonoral ame: CUMMINS, TAD ERIC DOB. SSN Education Lovel: 2Year College ‘ender: Nale Liconses & Endorsomonts Description (Type) [status pate Received Jxpiation Date Renewal Dato UM. Tpprentce iraahe= |Occupational Educ (27) |Superceded learazrant 1 joers1/2016 7 Fath Sence/Oceupalions (577) Prtessonl en oaranora — Yowarvanza 0 Health Sclence/ Occupations (677) Click here for a brief description ofthe type of icenses. Basle leonse siatus definitions Pending Review - application has been received, entered inlo database, given to licensing specialist for review. Application wil stay in thie slatus unt reviewed and eligibility determined, Requirements not met - application has been reviewed and deficiencies determined. You will ecelve ‘correspondence from licensing specialist defining the deficiency. ‘Active status - applcation reviewed with no deficiencies, cense was Issued. Education Education oes Calieee) State College Dato Degree Date Addod to Level eee Located Conferred Filo 2Year Columbia State Community yy ee a College (20) College This roflacts all educallon reported tothe Office of Teacher Licensing, Career Ladder Description No records found. ‘Tests Submitted to the Office of Toachor Licensing Description Score Test Date No tests found ‘Website only reflects tests reported to the State Department of Education, ‘Tosts That May Be Used For Demonstrating Highly Qualified Status Description Score Date Acquired No tests found that oan be used for Highly Qualified. Highly Qualified Test Search: Tests listed hore are only those found in the Department of Education fcensing database, Highly Qualified StatusSubject Grade Span No records found. ‘This information reflects Highly Qualified status as reported to tho stato by local schoo! systems. Educator Experience Bamtow yr asugnnent get fat aut rontaror — MauwrCrmly MeeTetr ee) goxzo69 010-00 7H corzoros | MauComy woTe Ee) sorsan30 o10-00 TN a S—r—SC TolaYeasionne Days 30.0 Foran ‘This information reflects all experience reported tothe State by local school systems through the last school year. The current academic yes is not included. Correspondence Recolved Dato Received Document Type 9n22011 ‘Occupational Advancement ‘8/14/2014 Occupational Application Disclaimer ~ This information fs based upon documentation recolved by the Office of Teacher Licensing. This Information i used for Hoensing purposes and is subject fo change upon further evaluation ofthe ‘documentation and in no way will guarantee the issuance of a Tennessee Teaching License. “information on this page may be purged after a designated period of time as determined by the Office of ‘Teacher Licensing." Please report eny webpage problems to the Application ManagerBl ha waited docementatrens —— to Tad We pens + 710 JAMES ROBERTSON PARKWAY 12TH FLOOR ANDREW JOHNSON TOWER NASHVILLE TN 97243 [PRINT CLEARLY - Please uso Black Ink o ensure scanned application Is lagible provide fullname - include any aliases. Saves eid = [or jasaenene sors pinnae tone see ad : Ene Cunumens tirireniforne [EGO BR lay sas pose Fecunomins®mauryrt2. ord lar ORATION NEEDED Foe PEDEUA-RESSTT: COMPCETE BOTH ETT a TCE 1. Ethnlety - choose one HlopanieorLatno__ Not Hispaic or Latino jz. Race- Choose one ormore American dian er Alaska Natve___ Aslan___ Back or Aan American Native Havaian - Other Pacis lelender ___ Whit PLEASE READ CAREFULLY BEFORE SIGNING - MUST BE COMPLETED JporsnalAfirmaton: Fite o complete thie aecton wil reult In your aplestion being returned without processing. Fave statements made inthis aration may cenatte ground tae acon, revoke or denyaicenss. Chock the aperépiss block or each question. you toned ya ost ona sey penta derecho es? pte yen es psn sat crete pl ly acrid eran poe |. Hee yeaa acho catifcatacera eked, suspended or dried, or have you luis rlingshad a catcaelconse low nang due mt eM ce ny ston paring ssi youcrstelicrs easton aot se? ne ee It yuna enswored oso questo or platelet of eorvtion Insane an gos of conisan, nd cour raed cries afte ppm conan, en sentencing ryote sewers o question 30r4 tach dete ning teats end isung etry a expan ckeunstnce pate X05] 23/20/4 Signature "TRANSACTION (S) REQUESTED. (Chock and complete folowing page) applicable) (CHOOSE TYPE OF INITIAL TENNESSEE LICENSE DESIRED (ts secon oNLy APPLIES TO THOSEHO [AVE NEVER HELD A TENNESSEE LICENSE OR DESIRING ADDITONAL LICENSE TYP) |NITALIGENSE'N eto Oy (rent, open Spacal Group, Bogknhg Antes, critters Leedsr) sdb one iro iat cae pen ere at NAR rere pene em [TUNITONAL LCSIGE (leases str fen MV Decl of cele vest for apr tian) {Tena LIGENGE (rete tgs fom Dal of School wu vector Dean of tans teal acer reparation een) [ITERA-o* LENGE (eiretip (aque slratref Osa of auesan tance prepara tr) ‘CGDUPATIONAL EDUCATION LICENSE pres espana). Psu (tere Ternane tating ess senor bs pil by Temes Publ Stes Sym) YEAR ATEFOUTIONAL CREDENTIAL ares preform Dek of Scho nero) “Rote UGENSe eerste fan TH Dhose Sat) ‘SecECHILANGUAGE PATIOLOOIT on SPCEGH ANGUNGE TEACHER OR SCHOOL AUDIOLOGIST NATIONAL BOARD GeRFICATICN "ADVANGEMENT TO APPRENTICE LEVEL OR PROFESSIONAL LEVEL LICENSE (OWL APPLICABLE I HELD A. PREDECESSOR TENNESSEE LICENSE _ADWANCEMENT FROM APPRENTICE LEVEL. TO PROFESSIONAL LEVEL (rasan orofesieal Sted Sonica Pans) ciclaane ‘AENANGEMENT FROM ALTERNATIVE“ A ar LTERQUATIVE“C" OR ALTERNATIVE“ TO APPRENTICE LEVE (pre oY Ot of Si) ane ADVANGE FROM AERA TONTTRENTICELEVEL (petener Oa) ota ‘ADVANCEMENT FROM ALTESNNTVE"T- OR ATEROATWE"X* Apron erat Star Presence. ‘vance Poa TUTTONAL en apne or Prosser) ‘Abiancecir FROM APORENTIOE OGCOPATIOWN. TO PROFESSIONAL OCCUPATIONAL LICENSE Conversion rol Teiesees TEAC LSE 0 SoHo. SERVICE PERGORNELLUGENSE.EpechLangung on) $DINICEMENT TO PROFESSION, LEVEL ADANISTRATOR UCENSE RENEWAL OF OR AMENDMENT TO AN EXISTING LIGENSE ‘ONLY APPLICABLE AKENDING A EXSTING TENNESSEE UCENSE RENEWAL OF LICENSE (Ose cre) Ever Uses (eeseopente Spec GramiOf St) JROTC __10 Year Llearee (Professir Spel Gre) —araistan lers (SogranaPreasen) 5 Year pais Ozupandliesan 10 eur Preto Oosipater Leese ‘Aural A(Goecchiang os). heii lawn) Tandon Non aad Cason ‘AIRMEN TO 50 AGDTHONA, GRE TO TEACHING LICENSE (Gn ho eg ath os! Vana) ‘Eure Dages Matas Dogs 90 samen yte haa" Econ Spent DosasleDegee ___RUONENT To ADD ENDORSEMENT AREA @) TO TEACHING LCENSE” (iy soa to oe) Aa CANGE teqaten a oaend copy ots manag coe, ee cnt a ats Genarind aaa at alge) Soa Sey als bore CHANGE NOTIACATIONo1/92-08/82- See Ae mee a vy a MERE ‘ama aRECE; VED JUL 21 204 Office Biviston of InstructionHUMAN. RESOURCESMaild 4-4-(| TENNESSEE DEPARTMENT OF EDUCATION - OFFICE OF TEACHER LICENSING 710 JAMES ROBERTSON PARKWAY 4TH FLOOR ANDREW JOHNSON TOWER NASHVILLE TN 37243 include any aliases PRINT CLEARLY - Please provi RET GLARE eee q ee Fn egret elaine lpr a onal ’ A Curin a sOKTE, ACH Mele Fah : IAFORMATION NEEDED FOR FEDERAL REPORTING - COMPLETE SOTH ETHNICITY & RACE 1. Etniiy-chooss one Visparc or Latino ___Net spain Race Choose one or mows Ameen iano Asia Nave flan Back san Arc Native Hawalian - Other Pacific Islander White. PLEASE READ CAREFULLY BEFORE SIGNING - MUST BE COMPLETED looronalAttrmaton: Palast complete tis ection wl reeutin your applestin bing retumed without processing Fae statement md inthis application may constiue grounds fo take acon, revoke or deny @eanze. Check the appropiets Bock fr each question, DO MOT include matters thatthe sino Board of Eduratin has aoa Svestgned end found No Probable Cause” to tak any dcipinay action. tse ou been ent ty nn comin nf ay, lef coer ro pain ei seston Ko Have you be cn te gente rg con pn ay poten on de goa pal ron? Ss uo eve youd a acer corexe ene rok sspnéer dria or hve you arta leds etcicnee (doing css x dens nl app? wee: ie a. tre any acon pcr gat or etter apaonin ante ste? “ves "0 you ve aavoredyes"to urstone tor pons tach etal of onion ncn ata place of conion and crc copes oh josgment conviction a setnsng. ciao stratus aoe 2 pec Only nL TRANSACTION (S) REQUESTED. (Check and complete following page(s) jrapplicabie) ‘CHOOSE TYPE OF INITIAL TENNESSEE LICENSE DESIRED (THis SECTION ONLY APPLIES TO THOSE WHO HAVE NEVER HELD A TENNESSEE LICENSE OR DESIRING ADDITIONAL LICENSE TYPE) INTIALLIGENSE-T intone Only (Apprentice, Apprenice Special Grup, Begening Mdina, or iach exter) cedeons UT OF STATE LICENSE (rata copter cts of TN/ USA ce aphing bata wpm ante spree). NONPUBLIC SCHOOL LICENSE Erployent vertietonequted) TRANSITIONAL LENSE: Gequtessinatr fom TN Delo of chose avian tom approved intuontgene/) = AATERIM"E UcENse peau gee ton oreors Sct a yt fo Dean of axnnceaton em tropa) = INTERIM-D" LICENSE (Raqutes signature of Dron of Education at sche rpaatin station) TZ OCCUPATIONAL EDUCATION LIGENSE (pprentoa Oocuptonal) PERM ine snot Tennosso easing Soa and can oy be ape fr bya Tanessne Pic Sebo Stem) YEAR INTERNATIONAL CREDENTIAL Roques snare for Desir of Sloss nowenenbis) IROTC LICENSE (Requitesslgnature fom TN Doct of Schools) 'SPEECHILANGUAGE PATHOLOGIST OR SPEECHLANGUAGE TEACHER OR SCHOOL AUDIOLOGIST [NATIONAL BOARD CERTIFICATION "ADVANCEMENT TO APPRENTICE LEVEL OR PROFESSIONAL LEVEL LICENSE (ONLY APPLICABLE IF HELD A PREDECESSOR TENNESSEE LICENSE) ADVANCEMENT FROM APPRENTICE LEVEL TO PROFESSIONAL LEVEL (Profcsosl or Profesional School Senice Personnel) cia ona ‘ADVANCEMENT FROM ALTERNATIVE" A" o ALTERNATIVE "0" OR ALTERNATIVE “ETO APPRENTICE LEVEL (Apprentice or Out Slt) one ‘ADVANCEMENT FROM INTERIM” B "TO APPRENTICE LEVEL (Aprenice Out ef'Sis) ce ona, ‘AOVANGEMERT FROM INTERIM D “TO APPRENTICE LEVEL, ‘ADVANCEMENT FROM ALTERNATIVE “I OR ALTERNATIVE I” (ppretie or Out Stator Prefeesina)silscrn [ADVANCEMENT FROM TRANSITIONAL (ppentos or Presson leone ‘ADVANCEMENT FROM APPRENTICE OCCUPATIONAL TO PROFESSIONAL COCUPATIONAL LICENSE CONVERSION FROM TENNESSEE TEACHING LICENSE TO SCHOOL SERVICE PERSONNELLICENSE (Speschtangunge ony) ADVANCEMENT TO PROFESSIONAL LEVEL ADMINISTRATOR LICENSE RENEWAL OF OR AMENDMENT TO AN EXISTING LICENSE (ONLY APPLICABLE IF AMENDING AN EXISTING TENNESSEE LICENSE) RENEWAL LICENSE (Chae oe) bear Licence AepenctApprontce Spell GrouiOut Stats) __10YearLcens ProfessionalPoessonal Spec Group) hier nee esheoietesans) Yew Ayseice Compara Leese _—10¥eur Prin Oops Lem ‘Atamatho (Speech Lang ony) Invim 8 —_Iniee)____Treltonal Nationa Bord Cerfiaton ‘AMENDMENT TO ADO ADDITIONAL DEGREE TO TENCHING LICENSE (Chosk one of i fcvig and tah oil recip) Mast’ Degree Eduaton Socal haters Degree #0 scastr ours Dextre Dopree “vENDMENT TO ADD ENDORSEMENT AREA (6) TO TEAGHING LICENSE (ery aren tobe ade NAVE CHANGE fits wrt a may ewe, re doze, cht ede al a ee 5 ela Sing Sa Sona ow ‘ADDRESS CHANGE NOTFICATION [DUPLICATE LICENSE Curl Teese noo sss LTH | ITI alent tate am page revezest9/09/2011 99:42 9319672594 CULLEDKA UNIT SCHOOL Pace 02/83 + Maury County Public Schools Employee Information Completion Verification For New-Hites/Re-Hires Licensed and Classified Personnel Tad Cumin — ulleoka ___to begin employment as a teachers 5 Employee is secking the following teaching credential: ok (@ N kere _-ss—trsts Ht sources Official ‘Completion Date of Orientation ‘This portion is to bo cotupleted by the Pstucipal/Depariment Head and returned to the Human Resources Dept, ‘Tho date to bo filled in should be the first day the exaployee actually reported to work, This date isto be used for payroll purposes. Payroll will begin on the date listed bolow, hhas completed initial paperwork and is now released to report fo . ~ e eS et Cos reatmnatnae_ reported to work on eu Employee Name * day on the job) we ADL shee Shae e Oalep osition. jchooi / Location Apres : A PB J ‘Head Signature Today's Date ce: payrouMaid 4-4-1 TENNESSEE DEPARTMENT OF EDUCATION - OFFICE OF TEACHER LICENSING 710 JAMES ROBERTSON PARKWAY 4TH FLOOR ANDREW JOHNSON TOWER NASHVILLE TN 37243 PRINT CLEARLY - Please provide fullname - Include any eases Feta caster an i ce ee ——— Maye. INFORMATION NEEDED FOR FEDERAL REPORTING - COMPLETE 80TH ETHNICITY & RACE +. Ethnicity -Choose one Hispanic or Latina Not Hispanic or Latino 2. aca Choose one or more American indlan or Alaska Native Aslan. Black ox Aican American Native Hawaiian -Othor Pact liander Wie PLEASE READ CAREFULLY BEFORE SIGNING - MUST BE COMPLETED personal Atimation: Fale t eomplts ti ection wil esl In your application belog retumed without processing. Fase sttements mace in thls |setication may consttit grounds othe acon, revoke or deny a eenzs. Check the approprnt block fr each question. OO NOT inelude matters that the stat Board of Education hae aired invecgeed and found "No Probable Cause” fo taka any deltinay actin, 1. ave you ben conve of ery, ncn anon nea gly, 2 les of clo contend re or rating petal Sveion? =a fave cuban conie tees posts of rs ng enon ona pl of iy, ‘ram Ser ging preven? Ko wtnoenmane “eo ave you hada teacher certcaaicnse revoked, sponded of dened or heve you valuta slngisSad cateteicaneo (abwing snes texte dons rol aps)? 4. te mere ay aon pening agent your earfctaficens or appleston nance a 1 you have answered "yes" to question 1or2 place aac deals of conviction, incudng date and pace of conviction, and [court erie copes ofthe judgment, convielon, and sentencing you nave anowered “yea” to qudeUone 3 or tach deals naming tp state andlor lsu author ens explain cioumstance. [Signature - eme —p “A Date 2-7 —H/ TRANSACTION (S) REQUESTED. (Check and complete following page(s) jFapplicabie) CHOOSE TYPE OF INITIAL TENNESSEE LICENSE DESIRED (THIS SECTION ONLY APPLIES TO THOSE WHO HAVE NEVER HELD A TENNESSEE LICENSE OR DESIRING ADDITIONAL LICENSE TYPE) INITIAL LIGENSE-TH netutone On (prec, Approntoe Speci Group, Bagering Ancien sader) —cieone (OUT OF STATE LICENSE (Progam coisas ous of TN/ USA or applying based upon Hirst atom). NONPUBLIC SCHOOL LICENSE (Emribynet verison requ) SRANISITIONAL LICENSE (Resins sont fom TH Oreo ef Schoen verteaton am approved nettatonlagenc)) INTERIM “B" LICENSE (feuies sire fbn Seo, ssn fon Dent senda ea aca pat hs) INTERIM-D" LICENSE (Requtes Sora of Deano Edueaton at acho preparation ston) ‘OCCUPATIONAL EDUCATION LIGENSE (pret Oreuptonl) PERMIT (Tia na Temestes aching inane a an only be sop aby eTeanossce Pubic Schl Sytem) S YEAR INTERNATIONAL CREDENTIAL Requtes snare om Diet: of Sess oenews) JROTC UCENSE (Reus sgnatue fom TN Dec ef Shoot) [SPEECH ANGUAGE PATHOLOGIST OR SPEECHILANGUAGE TEACHER OR SCHOOL AUDIOLOGIST NATIONAL BOARD CERTIFICATION ADVANCEMENT TO APPRENTICE LEVEL OR PROFESSIONAL LEVEL LICENSE (ONLY APPLICABLE IF HELD A’ PREDECESSOR TENNESSEE LICENSE) ADVANCEMENT FROM APPRENTICE LEVEL TO PROFESSIONAL LEVEL (Profesional or Prtesiond Schoo! Svc Peco) cle one ADVANCEMENT FROM ALTERNATIVE" A” o ALTERNATIVE"C" OR ALTERNATIVE" TO APPRENTICE LEVEL (Apprentice or Out of Sao) s one ‘ADVANCEMENT FROM INTERIM B" TO APPRENTICE LEVEL (Appenten or ato Stet) ela ne, ‘ADVANCEMENT FROM INTER“ "TO APPRENTICE LEVEL [ADVANCEMENT FROM ALTERNATIVE"I” OR ALTERNATIVE" (ApprenecrOutt Stator refed) iis na, [ABVANCEMENT FROM TRANSITIONAL Appronc of Professions sie ne ‘ADVANCEMENT FROM APPRENTICE OCCUPATIONAL TO PROFESSIONAL OCCUPATIONAL LICENSE ‘CONVERSION FROM TENNESSEE TEACHING LICENSE TO SCHOOL SERVIGE PERSONNEL LICENSE (Gpeeshtangunge ory) [ADVANCEMENT TO PROFESSIONAL LEVEL ADMINISTRATOR LICENSE RENEWAL OF OR AMENDMENT TO AN EXISTING LICENSE (ONLY APPLICABLE IF AMENDING AN EXISTING TENNESSEE LICENSE) RENEWALOF LICENSE (Chek one) 8 Year License AppreiiostApprenice Speci Grout of Sa) — Aare ane aggro) 8 "Yer Peter! Ospina ‘Atmabro A (Speech LOG.) Taran! Natonal Boars Cercaton ASIENDMENTTO A9 ADDITONAL DEGREE TO TEACHING LICENSE (Choa one oe alawing ands sl tener) ——Mastrs Degree Education Spoil tests Begee «20 somestr burs Desteale Depo ‘RENDNENT TO ADD ENDORSEMENT AREA (6) TO TEACHING LICENSE (ery seatobedées) NAME CHANGE Gago outa cny of taro Kr, ae ace, cout abl eee hana Sap) Soda Sua OSs [ADDRESS CHANGE NOTIICATION [BUPLCATE LICENSE Cure tTratna ney Rabe seandpgea enti rte HTL ‘0 Year license PreesonsPrtestnnl Speci Ge) / Hl emam page revezeatPLEASE POST MAURY COUNTY PUBLIC SCHOOLS 501 West Kighth Street Edward A. Hickman, Director of Schools Columbia, Tennessee 38401 (931) 388-8403, extension 0119 wew.manryk12.0rg Jobline (931) 388-8403, prompt 2 DATE OF POSTING: REPOSTED JULY 8, 2011 POSITION: *Health Science Teacher *Pending Funding for 2011-2012 SY DESCRIPTION/QUALIFICATIONS: ‘The Teacher shall be responsible for teaching Health Science Instruction, and all assignments as made by the Principal which shall include, but is not limited to coaching, and/or extra co-curricular duties and any other duty as assigned by the Principal. Must have RN Certification and 3 years experience in last five (5) years, and any other appropriate endorsement, certification, training and experience. ‘ JOB LOCATION: Culleoka Unit School APPLICATION DEADLINE: Indefinite SUBMIT APPLICATION TO: ‘Human Resources Department 501 West &* Street Columbia, TN 38401 ALL APPLICANTS MUST REQUEST AND COMPLETE AN EMPLOYMENT APPLICATION FROM THE HUMAN RESOURCES. DEPARTMENT OR WWW.MAURYK12.0RG, AS PART OF THE APPLICATION PROCESS. CCorrent federal nw requires identification and eligibility verification prior to employment, One or more ofthe following documents must be provided prior to issuance of an employment contract: EMPLOYMENT AUTHORIZATION IDENTIFICATION Social Security Card State Drivers License Contficate oF US. Birth USS. Passport or ather approved US. Passport or other approved U.S, Goverment dacaments U.S. Government documents NOTE: IP THERE ARE ANY ACCOMMODATIONS YOU MAY NEED IN ORDER TO INTERVIEW AND/OR MAKE APPLICATION FOR ‘THIS POSITION, PLEASE CONTACT JERRY D, WILSON, HUMAN RESOURCES SUPERVISOR, AT 388-8403, EXT. 0119, AN EQUAL OPPORTUNITY EMPLOYER “The Maury County Board of Rdwation does not disertainate on he baste of rae, creed, religion, national origin, age gender, marital slots, disability or any ther tone rein he operation of ts educational programs arin personel administration,AGE 03/05 OL. 27/25/2011 13:31 9319872594 ‘CULLEDKA UNIT ScHOt MAURY COUNTY PUBLIC SCHO y RECOMMENDATION FOR EMPLOYME (LICENSED PERSONNEL) oe fs recomn (Name) as afulktime X parttime Health Sciences Teacher Position) Calleote — Effective 725/11 (Gekoo! oF Site) (Pate) ‘The following applicants were interviewed forthe position (included recommended applicant): APPLICANT'S NAME: RACE /SEX: DATE OF INTERVIEW: ‘Ted Comming wa msm, (additional tines are needed, use the back of this form) {ceri that Ihave reviewed my recommended applicant's employment application and supporting documentation including “ES that are filed in the Human Resources Department, Maury = so on teats Ace RR Tem -7 ~Ile- /, DO OTE BE TNE HUMAN RESOURCES DEPT. USE ONLY The recommended applicant; (check all appropriate items) ——hss completed application on file; _/ has 8 TN teacher Licenses ___has the appropriate endorsements; Nill require a waiverfor,__ + __will require a permit; Will require a transitional license —Prpllant is Highly Qualified in the ae of Sine Karey L). Wher — Date ae eeePace, (CULLEOKA UNIT SoHOOL, 7/25/2011 13:31 9319872594 CULLEDK/ CONFIDENTIAL MAURY COUNTY PUBLIC SCHOOLS CONTACT REPORT THIS FORM IS TO BE COMPLETED BY THE PRINCIPAL/SUPERVISOR/INTERVIERER, 24/05 Applicant's Name _Tad Cummins Overall Rating: _Outstand FedGamming Outstanding (600 #9 on tack offre) Telephone Number(s) Home: Work: ee oa | ‘Special Notes: 7 __ Positions for which the person was contacted: Teacher (grade level and subject area) _ Health Sciences Teacher Approximate time the applioent was contactedlor attempted to be contacted: iW Pa 36 Date T2Vi1 Date Date, Date interview was scheduled: (applicable): 72/11 (Complete other side ofthis form if an interview was conductady > 1s this applicant stil itarosted in employment? CONo (o9) Yes Ifo, state reason Se ay cai a ric Sapenior ON (Return a copy of this completed form tothe Hurnan Resources Department fr all applicants efter the interview process is completed)10, Prior teaching experience 11. Other rfevant factors AGE CULLEDKA UNIT SCHOOL 97/25/2011 13:31 9319872534 5 MAURY COUNTY PUBLIC SCHOOLS TEACHER INTERVIEW RECORD Applicant's Name _Tad Cumming Dae _7asiit Position Applied For: _Health Sciences Teacher Health Sciences Tench —— Employment Criteriax (Check value for each area) ‘Strong Avemge Weak 1, Recommendations of persons having Yelevant knowledge ofthe applicant x Comments Outstanding = “Average Poor 2. Academie record and achievement x Comments: ‘Ouisending = Average Poor 3. Practioe teaching experiences; Coments: x ‘Ouistandlng” = “Average Poor 4, Other exparience beneficial to teaching: tar Comments Ouistendiig” “Average 5. Attitude and enthusiasm toward teaching and children: x Comments Dedieated iets ‘Unaceepable 6 Gramma, speoking, and other communication skis: ox Comments: Excellent ‘Raeae Wnsceepiable 7. Compatibitty: with other school staff, program and community: TE Comments: ‘Average accep ‘Commitiment to professional excellence and Ieteriy: x =e ‘Comments: Dediesled ‘Acceptable’ Thacoopiable 9. Overall Rating: x —— Hy Ousianding = “Average Poor _ Signauure “roe 85/05a7/26/2011 13:31 9319872594 CULLEDKA UNIT SCHOOL Pace 02/85 a. MULTEITCULL 1H UBUD A Haury county B,0.E, FAK NO. 931 640 4410 P, 01/01 CONFIDENTIAL, SCHOOL: Cub boepen. REPLACING: Qi Pasruan MAURY COUNTY PUBLIC SCHOOLS COLUMBIA, TENNESSHE HUMAN RESOURCES DEPARTMENT RECOMMENDATION FOR INTERVIEW ‘The following individuals arein the poo! of ayplicauts Zor the posted position, The principal/snpervisor fadfoates ‘tho xenults of eontacts or attempts to contact the applicants on the individaa} contact report, AL! i isvecommonded for employment. (also attach “Recommendation Yor Employment Form) Reason tis applicant was esleted over others? ATTAGH ¢RIECOMMENDA Prinllapdporviso Signatnes : DateLEA Background Check - Results Department of Children’s Sarvi¢os ‘State of Fonnesseo: Home EaRISearch iSiiSielp ESEsiDemo EaIRLogout Page 1 of 1 (thank out "No evidence was found in DCS records that the person was indicated as a perpetrator of Your search details: Confirmation Number: 141329 od SS Name: Tad Cummins Maiden Name: At Last Name 1: At Last Name 2: At Last Name 3: Ae Last Name 4 Request Date: 7/25/2014, Requested By:Gianina Chard ‘School System: Maury County Please save or print this for your records. (Erne) (Ceencet) ‘Copyright © State of Tennersne “a ota eb So ofthe Stee of Tennessee hittns://desbackgroundcheck.tn.gov/LEAResults.aspx 7125/2011APPLICATION FORM Licensed Personnel Maury County Public Schools MAURY COUNTY ; PUBLIC SCHOOLS: Columbia, Tennessee Date:___07-06-2011 Name____ CUMMINS Last Middle/Maiden Present Address Sai =, -_ City, Zip Code Permanent Address $7 ‘Street = = =e _= ty ‘State Zip Code POSITION FOR WHICH YOU ARE APPLYING: (Check all that are appropriate) W Teacher 17 Administrator F Other Coaching _ (Specific Area(s) (Applicants for coaching positions should include a summary of their athletic experience) AVAILABLE STARTING DATE: 06-2011 ‘A. LICENSE/ENDORSEMENT AREA(S) Do you hold a valid Tennessee Teachers License? Bi: W No If yes, TN License Type: Out of State TN Teacher Career Ladder Level: PCL T Apprentice Teacher recur TT Professional License CLO AREA(S) OF ENDORSEMENT: If no, have you applied for a Tennessee Teacher License? I Yes W No Tf no, why not? Do you hold a Teacher license in another state? [~ Yes [7 No Tf yes, list state __ AREA(S) OF ENDORSEMENT: Have you taken the National Teachers Examination? res WW No Please advise if you need any accommodation in order to interview for the position for which you are applying. Is there any accommodation you may need to perform the essential functions of the position which you are applying? (Optional) J" Yes 7 No If yes, please list accommodation. ee MAURY COUNTY BOARD OF EDUCATION IS AN EQUAL OPPORTUNITY EMPLOYER The Maury Counly Board of Education does not ciscriminate on the basis of race, creed, religion, natural origin, age, gender ‘marital status, disability or eny other unlawful area in the operation ofits educational programs and activities including employment practices. 3/10B, PERSONAL DATA ‘Are you a citizen of the United States? 7 Yes. [~ No 2. Are you a 18 years of age or older? WYes [No C, EDUCATIONAL PREPARATION 1, Degree(s): [- Bachelor's [Master's F Specialist Doctoral (Attach Official Transcripts) 2, College Grade-Point Average based on a 4.00 Scale: 3,5 7 (Bachelor's Degree) 3. GPA. in major subject field on a,4.00 Scale: _ 4. SCHOOLS ATTENDED: High Schoo! Uist begiee * “Glee or Adress atenies | Mair | orDipiona | tte, ook et date MTPLEASANT Hk|600 GREENWOOD STREET, MTPLEASANT,TN. [6 GENERAL sTUt|Hs DIPLOMA| of igh schon _ = By ‘geduaton. couumsia srg] 1665 HAMPSHIRE PIKE, COLUMBIA,TN ove 2 espcare [ans | a5/07/1993 Other educational experiences, honors, etc. On January 30, 1995, | participated in the American Heart Assn’'s Schoo}-site Program by conducting (and speaking at) a workshop at J.E. Woodard Elementary School to teach ‘teachers how to use kits provided by the A.H.A. to teach children how to live a “heart-healthy” lifestyle. 5. Major(s) RESPIRATORY CARE TECHNOLOGY. 6. Minor(s) 7. ‘Student Practice/Teaching (For applicants with less than two years of experience): Grade or Subject oe 8. No. of Weeks 9. Location of Student Teaching _ os 10. Name of Supervising Teacher 11, Phone No. 12, Address __ D. WORK EXPERIENCE 1. TEACHING EXPERIENCE: (Most Recent First) ‘School, Address & Name of| Reason | Grade No. Schoo! System Princpal | for Leaving | Taught | Sebsects | Date PostionGnd D. WORK EXPERIENCE, Cont. (Mark N/A if not applicable for questions 2 and 3) 2 Total years of teacher experience in Tennessee: Public 0 __ Private 0 3. Total years of teacher experience out of state: Public O Private 0 4. Have you ever failed to be re-elected? T Yes W No 5. OTHER WORK EXPERIENCE: (Most recent First) ‘Type of io. son Position Employer - Address ~ Phone No, poeta | Soave | Paes 1 M2 | gta Rese | AT HOME WEDICN. SUPPLIES 615-335-3552 ‘camca, [eaTnenne 2-207 |, | PRESENTLY [THeRaPisT [350 WALLACE ROAD, NASHVILLE, TV Hauswan | PRESENT EMPLOYED Rese | TACMEDICAL cis ea2-0114 7201070 a |THERAPIST | 4323 CAROTHERS PKWY, STE 301 FRANKLIN, TN baa DEFF WALKER 112011 ee FF IBRANCH | MEDICAL NECESSITIES 931-698-4309 paxter |&2009 70) [TO TAKE /MANAGER —_|907 W JAMES CAMPBELL BLVD, COLUMBIA, TN ee ee }7-2010 fe TLC 308 RESP | AMERICAN HOMEPATIENT 615-652-0881 ‘camca, | TRENT Fra007 70 |p *(TOTARE rTHerapisr [5211 LINBAR DR, STE 505, NASHVILLE, TH nessicx [6-209 MEDNECI0B If previously employed by Maury County Board of Education, list below. Schoo/Site Peston Supervisor Dates E. REFERENCES Please list below people to whom we will refer concerning you professional preparation and experience. List only persons who know of your training, experience, or other qualifications for educational service. (Send professional reference request form to the three individuals you lst below. Name of Reference Complete mating Adress and Phone No. Busines Ocupation KATHERINE HAUSMAN 350 WALLACE ROAD, NASHVILLE, TW 37213 615-339-3992 nr HOME MED/OFFICE MGR DAVID BAXTER, RN 907 WANES CAMPBELL BLVD, COLUMBIA, TW 3801 951-698-4309 | MED NEQOWNER er WaKER 2223 CAROTHERS Pkwy, STE 201 FRANKLIN, TH 7064 61562-0114 | TLCICO-OWNER After an offer of employment has been made to an applicant and prior to commencement of employment duties, each employee shall present to the Human Resources Administrator a physicians certificate ("Report of Medical Examination” form) showing a satisfactory health record. Physician's fees shall be at the expense of the employee. "Report of Medical Examination" forms will be obtained from Maury County Board of Education's Human Resource Department. With the exception of substitute teachers, according to board policy 5.115, members of an Immediate family shall not be assigned to the Instructional staff in the same school plant. Immediate family shall be defined as spouse, child, parent, parent-in-law, brother, sister, brother-in-law, and sister in-law. List any relative currently employed by the ‘school system, thelr position, and relationship to you: LL CUMMINS, INSTRUCTIONAL ASSOCIATE, MY WIFE F, IN YOUR OWN HANDWRITING, MAKE A BRIEF STATEMENT ON WHY YOU HAVE CHOSEN TEACHING AS A PROFESSION: J have-ol?e) tought thieZ would louetobepvenchess anf just might excel! 97) tpbar i-nprer stp e Ned pba Set7: ave When Pie spportyas?-y pred chted H-ce/tL recifed Har one-oF my tuet/es. eicherc caméto tench 1g pl A-seeo hd chp eet, THAT hed oe, me-to £2) '2veE TATE LAN FOO »G, STATE REQUIREMENT INSTRUCTIONS: READ THE INFORMATION BELOW, ANSWER THE TWO QUESTIONS, AND SIGN AND DATE AT THE END OF THIS SECTION. | recognize that if| am employed, the Director of Schools will assign or reassign me to a specific position as the need requires. UNDERLINE HAVE OR HAVE NOT. 1. hereby certity that | (have) (have not) been convicted of a misdemeanor or a felony in any state of the United cee (cave nol) | *have" is indicated, explain fully the details of each such conviction on a separate sheet of paper. 2. | further certify that | (have) (have net) been dismissed from any previous employment for improper or unpro- fessional conduct, inefficient service, neglect of duty, incompetence, or insubordination as the same are defined in Sections 49-5-501 of the Tennessee Code, If "have"'is indicated, explain fully the details of each dismissal on a separate sheet of paper. The employer's rnon-renewal of a yearly contract need not be indicated unless the non-renewal was for cause as listed above. I my most recent employer were another Tennessee public system and if my termination were voluntary, | hereby certify that my resignation was, or wll be Submitted at least 30 days prior to the beginning date stated hereon; or, if within 30 days, that the previous board has waived its right to such notice. A copy of my letter or of registration or of the said board action is attached or will be provided | understand that misrepresentation of any of these certifications may subject me to the penalties prescribed In Section 49-5-406 of the Tennessee Code. Providing false information as to a conviction of a misdemeanor or felony in this state or any other state shall be sufficient grounds for termination of employment and shall also constitute a Class A misdemeanor which must be reported to the District Attomiey General for prosecution. The accuracy of such information may be verified by fingerprint and criminal history records check conducted by the Tennessee Bureau of Investigation pursuant to T.C.A. 49-5-413(a). ! authorize a complete background check including but not limited to criminal investigations and the result thereof be submitted to Maury County Board of Education. understand that, if| am employed, the Board of Education may assign me to a specific position as the need requires. | certity that all applicable questions on the application have been completed, that the information provided is accurate, and understand that withholding information ot providing inaccurate information may be grounds for invalidating a contract. If further understand that this application will become part of my permanent personnel file should | be employed by the Maury County Board of Education. | urther certify that | give permission for information concerning past employment to be released fo Maury County Board of Education, Ln xf by Retum this application to: Director of Schools Maury County Public Schools 501 West sth Street Columbia, Tennessee 38401 Attn: Human Resources Dept. (931) 388-8403 ext. 0118 ‘Signature of Applicant Applications are kept on active file for one (1) year. Applicants must make a request in writing if they wish the application to remain active for an additional year. Completion of a new application may be necessary.Maury County Public Schools Confidential Application Information Licensed Personnel Name CUMMINS TAD Last First Phone No: Hore emg Susioss Social Security Number: __ —— bate of it: SN sac TN Teacher License No: Date License was issued: Date License expires: Highly Qualified Information Are you highly Qualified: © 7 YES w NO How can you prove Highly Qualified (Check Appropriate Options): General Options House Options (Existing teachers only) TT Academic Major T Professional Matrix J” Coursework Equivalent Teacher Effect Data [” Graduate Degree J Framework for Evaluation and |” National Board Certification Professional Growth 1 NTE(Praxis Test [> Proven HQ in another State List your proven core academic subjects: “This form must be completed and submitted with application.Academic Transcript Academic Transcript Page 1 of 5 400113930 Tad Cummins Jul 06, 2011 10:05 pm ‘This is not an official transcript. Courses which are in progress may also be included on this transcript. Institution Credit Transcript Totals ‘Transcript Data [STUDENT INFORMATION [Student Type: |centinuing = (Curriculum Information i [fAssociate of Applied Science Prograr es “Resp Care" = Sa a Co ‘State Comm [eee Se ‘state Main pus ator and Department: [Reset Soe | iRespiratory Cave ‘**Transcript type: WEB Web Transcript is NOT Official *#** DEGREE AWARDED Namet |fad Commins sto (Degree Date: |Primary Degree |Prograr [[Acmitted Resp Care AAS degree 1 ee | ‘Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points |__| 0.006) _o.o00l| .000]| 0.000] oa =] Td [Magna Cur Laude https-//banner3.columbiastate. edu/pls/PROD/hwskotm.P.ViewTran U6I20ULAcademic Transcript Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points MEET Caco op y Start RCEU Subject Course Level Title Hours Points and Contact End Hours Dates | *3.000}) 42.000] _ ——_ feel teteest Attempt Passed Earned GPA Quality GPA | jours Hours Hours Hours Points | | ‘acl 4.00] 4.00] 4.00]. Sa o0o]{ "4-000 300% ‘Term Totals ae Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points "Fee ea aah zoo smi} | ) i; | | | [subject Course Level Title Grade Credit Quality Start Rcev | / Hours Points and contact Hours tat Toten (pte meee Socees) Attempt Passed Earned GPA Quality GPA Hours Hours Hours fous Points ‘Term Totals (Undergraduate) | Attempt Passed Earned GPA Quality GPA https://banner3 columbiastate.edu/pls/PROD/bwskotm.P_ViewTran Page 2 of 5 62011Academic Transcript Page 3 of 5 | Hours Hours Hours Hours Points {Garrone ferme lf |[cumulative: ~_|L__ 40.009} [Fall Semester 150% a subes CourseLevel Title ~*~ ade. Gredit Quality Stare CEU Hours Points and Contact| 1 End Hours Dates — eo | aan fae antes see ein “| fl Q r ia jist eee boa a.c80| PE Fike Ae | ‘Term Totals (Undergraduate) Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points alse. | 23.000)[ 23.000], —23.000|| 23.000] ~6.000]] 3.725] | Grade Credit Quality Start R CEU Hours Points and Contact. End Hours Dates (pS er : as (See eed hnickostouocy | i2.000) (are ae ocean ~—s | i GNOLOGY — eee : "Term Totals ae Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points —— a | o0o ee ooo 3785) fi 3750) hitps://banner3.columbiastate.edu/pls/PROD/bwskotm.P_ViewTran ‘T6201Academic ‘Transcript Subject Course Level Title Grade Credit Quality Start Reev | Hours Points and Contact End Hours Dates | \eaxoron | Ianarrenrs. | [ARTERIAL BLOOD fy 1 ionses 2s cian o [Term Totals (Undergraduate) Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points [20.00 tooo] sacs i. Grade Credit Quality RCEU Hours Points and Contact) End Hours Dates ue aie jive ‘Term Totals (Undergraduate) ‘Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points 3 000||_33.000][_43.000][—— 3.08] [53.00 63.000] 220.000] ss 3.000] ‘Quality Start R CEU Hours Points and Contact, End Hours Course Level Title ‘Subject [ia Jue eonrost jee eaniae iner |SeMmaR IL = i PPATHO/PEDIATRICS | Term totais (Undergraduate) | ‘Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points ET htips://banner3.columbiastate.edu/pls/PROD/bwskotm.P_ViewTran Page 4 of 5 7116/2011Academic Transcript current re | Unofficial Transcript [TRANSCRIPT TOTALS (DEVELOPMENTAL STUDIES) — -Top- Attempt Passed Earned GPA Quality GPA Hours Hours Hours Hours Points 30 SBS col | | | | | | | nota Transp | TRANSCRIPT TOTALS (UNDERGRADUATE) -Top- | | i Attempt Passed Earned GPA Quality GPA Hours Hours Hours Points are le SST ean el on STs tae 0 ‘Attempt Passed Earned GPA oa Quality GPA vera Combine Unofficial Transcript RELEASE: 8.1 hittps-//banner3.columbiastate.edu/pls/PROD/bwskotm.P_ViewTran Page 5 of S 6/2011‘Tad E, Cummins, RRT E-mail: tadeummins@att.net PERSONAL HISTORY Education: ‘On May 7, 1993, I graduated Magna Cum Laude from Columbia State Community College achieving an A.A. degree in Respiratory Care Technologies. On December 4, 1993, I sat and passed the National Board Exams for Respiratory Care, achieving the title of “Registered Respiratory Therapist”. I currently hold a Tennessee therapist level license. In 1984, I graduated from Mount Pleasant High School in Mount Pleasant, Tennessee, receiving my high school diploma from general studies, including six years of band (percussion). ACHIEVEMENTS/COMMUNITY SERVIC! Thave been a percussionist since the late 1970’s. I have played in several bands over the years, and I am an active set drummer and a conga player/percussionist. I am also a singer/songwriter and guitar player, and I ofien perform as a solo act. I currently hold around 65 song copyrights. I write most of my music with my guitar, piano, or behind my congas. Tam a Christian, and I worship at the Grace Church of the Nazarene in Columbia, TN. Iam blessed to have served in many capacities at Grace, one of which is that I oversaw all audio engineering and sound equipment for the Grace Church campus. Another is a ministry called “Grace Unlimited”, in which we ministered, monthly, through worship services, fellowship, and mentoring at Maury County Jail and at Magnolia Academy (a wildemess boot camp for teen boys in trouble). Within this ministry, I was blessed to get to minister to many individuals through preaching, playing music, leading singing, singing solos, praying, and mentoring. At Grace Church, [have served as a church board member, a Care Pastor, taught adult and teen Sunday school classes, sang in the Choir, played drums during Sunday worship, and I occasionally serve as a vocal soloist. T also served as Interim Youth Pastor and often serve as an adult chaperone for youth activities. March 15-23, 1996, I traveled to the Darien Province in the rainforest of Panama to participate in a medical mission campaign in which we spent a week conducting clinics in various jungle communities and treating the ‘medical problems of the Embura Indians. In 2005, I traveled with HCA to Louisiana for 2 weeks to do disaster relief in the immediate aftermath of Hurricane Katrina. On July 18, 1999, I completed requirements and was awarded the rank of Black Belt in Kenpo Karate.have developed and served as webmaster of several web-sites including www.tadcummins.com, www.cryforholiness.faithweb.com, www.cumminsmartialarts.com, and www.comyngar.freeservers.com, www.cumminsmartialarts.com was a full service e-commerce web-site. Ihave been certified by the American Heart Association in Basic Life Support, and I have been a BLS Instructor. I have also been certified in Advanced Cardiac Life Support and Neonatal Resuscitation. On January 30, 1995, I participated in the American Heart Association’s Schoolsite Program by conducting (and speaking at) a workshop at J.B. Woodard Elementary School in Columbia, TN to teach teachers how to use kits provided by the A.H.A. to teach children how to live a “heart-healthy” lifestyle. WORK HISTORY Respiratory Therapist —At Home Medical Supplies, Nashville, IN Since February 2011 Tam a homecare therapist. perform initial and long-term management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups. These include CPAP therapy, BiPAP therapy, humidification therapy, aerosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to / following up on the results of those evaluations in an appropriate and timely manor. I also perform respiratory care supplies management, documentation in compliance with regulatory authorities, scheduling of patient visits, frequent sales calls with and without our Account Executives, clinical education presentations to patient source accounts, and I oversee all clinical activities. During my tenure, I have also helped the company prepare for CHAP accreditation. Respiratory Therapist - TLC Medical, Franklin, TN & Columbia, TN July 2010 — January 2011 Twas a homecare therapist. Iperformed initial and long-term management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups. These included CPAP therapy, BiPAP therapy, humidification therapy, aerosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to / following up on the results of those evaluations in an appropriate and timely manor. Talso performed respiratory care supplies management, documentation in compliance with regulatory authorities, scheduling of patient visits, occasional sales calls with our Account Executives, clinical education presentations to patient source accounts, and I oversaw all clinical activities for the Franklin & Columbia offices. During my tenure, I helped the company prepare for CHAP accreditation, Respiratory Therapist / Branch Manager — Medical Necessities & Services, Columbia & Murfreesboro, TN Tune 2009 — July 2010 ‘As a homecare therapist I performed initial and long-term management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups. These included CPAP therapy, BiPAP therapy,humidification therapy, aerosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to/ following up on the results of those evaluations in an appropriate and timely manner. 1 also performed respiratory care supplies management, documentation in compliance with regulatory authorities, scheduling of patient visits, and clinical education presentations to patient source accounts, and I served as a Clinical resource for the rest of the office staff. ‘As Branch Manager I was responsible for the managerial, budgetary, and clinical oversight of the Columbia operation including: staff supervision, employee hiring/training/retaining, flow of orders, timeliness of delivery, ‘patient and referral source satisfaction, assisting / advising sales staff as needed, tracking billing, tracking patient follow-up, setting and tracking goals for the office, the staff, and me, ordering, inventory tracking and contol, cost-of-goods tracking and control, oversight of and responsibility for an approximately $4 million budget, compliance with governmental and accreditation agency regulations and directives, timely reporting and communication with the company’s president, vice president, and COO. Respiratory Therapist - American Homepatient, Nashville, TN July 2007 ~ June 2009 Twas a homecare therapist. I performed initial and long-term management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups. These included mechanical ventilator ‘management, CPAP therapy, BiPAP therapy, humidification therapy, aerosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to / following up on the results of those evaluations in an appropriate and timely manor. I also performed respiratory care supplies management, documentation in compliance with regulatory authorities, scheduling of patient visits, occasional sales calls with our Account Executives, clinical education presentations to patient source accounts, and I oversaw all clinical activities for the Nashville office. Ialso was utilized by American Homepatient’s home office to present the clinical portion of their quarterly “new account executive orientation”. This involved educating approximately 30 new AEs each quarter on the basis of cardio-pulmonary anatomy and physiology, and the abnormal pathophysiology of COPD and other respiratory disorders. During my tenure, we successfully went through JCAHO and ACHC accreditations. General Manager — Medical Necessities & Services, Nashville, IN April 2007 — July 2007 T was the General Manager of the Nashville branch as well as the only Respiratory Therapist for that office. Since this office was a new start-up, I was basically an entrepreneur. I secured office space, dealt with realtors, secured and dealt with architects and contractors, designed the floor-plan, made interior design decisions, secured telecommunications (voice & data) equipment and installers, purchased computers, hired employees, and all other details of a new build, office set-up, and office start-up. T also came up with our corporate branding concept, designed the artwork, secured a contractor to place vinyl signage on our flect of delivery vans and PT Cruisers, and secured a contraetor to “brand” our office signage. I was responsible for the managerial and clinical oversight of the Nashville operation including: staff supervision, employee hiring/training/tctaining, flow of orders, timeliness of delivery, patient and referral source satisfaction, assisting / advising sales staff as needed, tracking billing, tracking patient follow-up, setting and tracking goals for the office, the staff, and me, ordering, inventory tracking and control, cost-of-goods tracking and control, compliance with governmental andaccreditation agency regulations and directives, timely reporting to our corporate office, and communication with the company’s president, vice president, and CFO. As the only Respiratory Therapist in the Nashville office I performed initial and long-term management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups. These included CPAP therapy, BiPAP therapy, humidification ‘therapy, aerosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to / following up on the results of those evaluations in an appropriate and timely manor. 1 also performed respiratory care supplies management, documentation in compliance with regulatory authorities, scheduling of patient visits, and clinical education presentations to patient source accounts, and I served as a clinical resource for the rest of the Nashville office staff. During my tenure, I helped the company prepare for CHAP accreditation. Respiratory Therapist - Mid-South Medical and Mobility, Nashville, TN June 2005 — April 2007 Twas a homecare therapist. performed initial and long-term management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups. ‘These included CPAP therapy, BiPAP therapy, humidification therapy, aerosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to / following up on the results of those evaluations in an appropriate and timely manor. 1 also performed respiratory care supplics management, documentation in compliance with regulatory authorities, scheduling of patient visits, and clinical education presentations to patient source accounts, and I served as a clinical resource for the rest of the Nashville office staff. During my tenure, we successfully underwent ACHC accreditation. Respiratory Therapist - Williamson Medical Center, Franklin, TN August 2004 — June 2005 Duties included responding to “Code Blue” calls, mechanical ventilator management, other critical care ‘monitoring and therapeutics, aerosol therapy, oxygen therapy, hyperinflation therapy, arteriotomy, arterial blood gas analysis, EKGs, institution, evaluation, and modification of therapist driven protocols, and other duties of respiratory care, Respiratory Therapist - Mid-South Medical and Mobility, Nashville, TN ‘May 2004 — August 2004 T functioned both as a homecare therapist and an outside sales representative. I performed initial and long-term ‘management of respiratory modalities and respiratory patients including pediatric, adult, and geriatric age groups, respiratory care supplies management. ‘These included CPAP therapy, BiPAP therapy, humidification therapy, aetosol therapy, oxygen therapy, clinical patient evaluation / monitoring, and responding to / following ‘up on the results of those evaluations in an appropriate and timely manor. I also performed documentation in compliance with regulatory authorities, scheduled and non-scheduled sales calls on patient source accounts, clinical education presentations to patient source accounts, and serving as a clinical resource for the rest of the Nashville office staff.Freelance Registered Respiratory Therapist EMS Medical Staffing [615-477-3725] and All About Staffing [615-565-6227] July 2003 — April 2007 I worked PRN for these two staffing agencies as a freelance therapist. I worked in various hospitals to fill in when they had staffing deficiencies. My clinical duties included responding to “Code Blue” calls, mechanical ventilator management, other critical care monitoring and therapeutics, aerosol therapy, oxygen therapy, hyperinflation therapy, arteriotomy, arterial blood gas analysis, institution, evaluation, and modification of therapist driven protocols, and other duties of respiratory care. Age groups served included neonatal, pediatric, adult, and geriatric. Assistant Director of Respiratory Care - Maury Regional Hospital, Columbia, IN June 2001 - July 2003 | was responsible for the direct supervision of the 7a -3p shift and the Supervisors of all other shifts. Twas also responsible for clinical oversight of all Resp Care activities. Age groups served included neonatal, pediatric, adult, and geriatric. I also served as a clinical resource for our staff, other departments, and numerous Physicians and Nurse Practitioners. I was in charge of all education for Resp Care, and I often conducted in- service education for other departments. My duties also included developing and instituting performance improvement and customer service programs for our department, yearly employee performance evaluations, employee scheduling, Employee payroll accounting and managing our equipment, supply, and medication inventories. I was the primary buyer for Resp Care supplies for our department. Also, I frequently served as a liaison between Resp Care and patients, family members, other departments, physicians, other healthcare organizations, vendors, and the general public. I mentored employees in order to help them develop the ability to deliver efficient, caring, and scientifically sound patient care. Additionally, I conducted monthly supervisors’ ‘meetings where I met with the rest of my department’s management team, participated in discussions, made strategic decisions on matters concerning the day-to-day operation of our department, and made recommendations to our department director on subjects such as staffing needs or capital budget needs. On two occasions of the director’s extended illness, I assumed the duties of the Director of Respiratory Care and reported to the assistant administrator. These two occasions totaled approximately four months. During my tenure as Assistant Director, Maury Regional underwent a major construction project which added three floors to the hospital. As a part of this project I oversaw moving the RT department twice. We also went thru a JCAHO inspection during my tenure as assistant director at Maury Regional. My clinical responsibilities included endotracheal intubation, responding to “Dr. Pacemaker” calls, attending “high-risk infant” deliveries to perform endotracheal intubation on neonates when indicated, mechanical ventilator management, other critical ‘care monitoring and therapeutics, aerosol therapy, oxygen therapy, hyperinflation therapy, arteriotomy, initiating the SEEK process, participating in SEEK committees, institution, evaluation, and modification of therapist driven protocols and clinical pathways, as well as, other responsibilities of respiratory care. I also served the hospital as a Basic Life Support (CPR) instructor. Respiratory Therapy Supervisor (1 1p-7a) - Maury Regional Hospital, Columbia, TN ‘April 1994— June 2001“My supervisory responsibilities included effectively assigning workloads to utilize all employees working that shift and insuring that all patient care was carried out in an effective and timely manner. I mentored employees in order to help them develop the ability to deliver efficient, caring, and scientifically sound patient care. I also conducted periodic evaluations of employees on my shift during which I reviewed their progress towards our goals for that employce and help them chart a course towards additional progress. Additionally, I attended monthly supervisors’ meetings where I met with the rest of my department's management team, participated in discussions, made strategic decisions on matters conceming our department, and made recommendations to our department director on subjects such as staffing needs or capital budget needs. My clinical responsibilities included endotracheal intubation, responding to “Dr. Pacemaker” calls, attending “high-risk infiant” deliveries to perform endotracheal intubation on neonates when indicated, mechanical ventilator management, other critical care monitoring and therapeutics, aerosol therapy, oxygen therapy, hyperinflation therapy, arteriotomy, initiating the SEEK process, participating in SEEK committees, institution, evaluation, and modification of therapist driven protocols and clinical pathways, as well as, other responsibilities of respiratory care. Age groups served included neonatal, pediatric, adult, and geriatric. T also served the hospital as a Basic Life Support (CPR) instructor. Respiratory Therapist - Baptist Hospital, Nashville, TN ‘March 1993 - April 1994 Duties included responding to “Code Blue” calls, mechanical ventilator management, other critical care ‘monitoring and therapeutics, aerosol therapy, oxygen therapy, hyperinflation therapy, arteriotomy, arterial blood ‘ens analysis, institution, evaluation, and modification of therapist driven protocols, and other duties of respiratory care. Age groups served included neonatal, pediatric, adult, and geriatric. We also went thru a JCAHO inspection during my tenure at Baptist Hospital. Student Respiratory Therapist - Williamson Medical Center, Franklin, TN August 1992 - March 1993 Duties included aerosol, oxygen and hyperinflation therapy, as well as, arteriotomy and various other responsibilities of respiratory care. Age groups served included neonatal, pediatric, adult, and geriatric. (This ‘was a part-time job while T was in college.) Service Advisor - Sears Automotive Center, Columbia, TN January 1991 - August 1992 Duties included retail automotive parts and service sales, effectively routing service customers through shop, and ensuring quality work, as well as, customer satisfaction. (This was a part-time job while I was in college.) Parts Manager - Bates Engine and Automotive Inc., Centerville, TN November 1989 - December 1990Duties included retail automotive parts sales, engine sales, overseeing sales and delivery staff, parts stock ‘monitoring and reordering, tracking sales, as well as, some collections work on past due accounts. I left this job to enter college to become a Respiratory Therapist. Sales Associate - Columbia Chrysler-Plymouth, Dodge, Columbia, IN April 1989 - November 1989 Duties included commission automotive sales, Plant Employee - Spontex Incorporated, Columbia, TN April 1987 - April 1989 Duties included various jobs in cellulose sponge manufacturing which required the use of vatious sizes of fork lifts and electric trucks, a semi-tractor and trailers, overhead eranes, and several types of computerized control boards and timing mechanisms. Office Manager - Petrolane Gas Service, Columbia, TN June 1985 - April 1987 Duties included retail propane and appliance sales, payroll processing, supervising delivery staff, supervising service staff, computerized accounting, computerized delivery truck routing, and general office duties. During my tenure at Petrolane, I successfully changed over the ledger accounting system and the cardfile truck routing system to computer based systems. Maintenance and Re-use Technician - Middle Tennessee Artificial Kidney Center, Columbia, TN March 1985 - June 1985, Duties included preventive maintenance on hemodialysis machines and other medical equipment, inventory and re-ordering of all medical supplies, and cleaning and sterilization of dialyzing filters. (This was a temporary position.)Maury County Public Schools NON - CONFIDENTIAL PROFESSIONAL REFERENCE REQUEST appuicanrs rULNAME: ZA Zer/c- Lamm, LAT APPLICANT'S ADDRESS: apetyine For postion as:_ Heath S7~/ CN lLE-7e: a PERSON COMPLETING REFERENCE FORM: APH AL. pA SAS Fata, [RS Aaa] Ss cereal [| = [71 == 70 = a = = a T - TF ee = | fi sero! A oe F wageimncnan | 7 : reer 7 aan ZT fei a a fa wesacton wth es - | — Al ed : fo, tay ad copsatn ale ee oo | renres 7 FF incite : i owemmncanonas | v7 | __ pi teers on =| ‘wate conmuvenin ts | 7 - hs. enmmirency a. bane fr. oper ets = ara GENERALRATING:_6 _ (OPPORTUNITIES FOR OBSERVING THE CANDIDATE : EVER FAILED RE-ELECTION? (i oer, PLEASE EXPLAIN.) FOYOUR KNOWLEDGE, HAS THIS “Riera SUBJEGTED TO ANY DISCIPLINARY ACTION, ASKED TO RESIGN, OR FO) iF YOU WERE PERSONALLY RESPONSIBLE, WOULD YOU RECOMMEND THE EMPLOYMENT OF THIS APPLICANTI(IE%8} Fino (QF NO, PLEASE EXPLAIN.) "ADDITIONAL COMMENTS: = : SIGNATURE _ (ithaggy lasagne ‘COMPANYISCHOOL, NAME: (Please Print) ne HAUSMAN] _ rooress 350 STAI poston Sino. aunger _ teh MAILTO: Diratr of Schoo}, Maury County Board of Eueation £501 West Gh Stout, Columba, TN 20404 ‘An Human Resources Dopt. (81) 988-0409, ex 0118 (ovenMaury County Public Schools NON - CONFIDENTIAL PROFESSIONAL REFERENCE REQUEST APPLICANT'S FULL NAME: APPLICANT'S ADDRESS: APPLYING FOR POSITION AS:_ 1 SACP. PERSON COMPLETING REFERENCE FORM: __DAVi0 jane fcr cess ty | [En [et cameo] ype cick ttn Lestat ee] |e [See er) eat a to =| SS = E i Reema fa sate I gee oven < ae [7 Promphness and 7 7 [2 tnteracton ith stents Tonga xs { “ [> tr eatin —_ eo Ma La mae [la [ catanemsanonte |S __ tetera Mla I wien comment fs emma arwmcina | 1q js. scans xK : [> terns | vl : lx a Pome TXT _t Be wove tng Sk Fert GENERAL RATING:_OV#aN, Tad 15 A Well rouwats _irvdivie hats vlc geylojeenl with us OPPORTUNITIES FOR OBSERVING THE CANDIDATE “Th wud 240 “Pvapst Be is Ou pabiecds: = th deer fejoy eins inrinelad by Wien, We had prysiciw Phat [kesh werk wit hin as tpl Tha ele Sovef Wel hb ove ct Pak evhanecel ovr pabeat ofeomes, 70 YoUR KNOWLEDGE, HAS THIg APPLICANT EVER BEEN SUBJECTED TO ANY DISCIPLINARY ACTION, ASKED TO RESIGN, OR EVER FAILED REELECTION? [1Yes X{No_ (IF YES, PLEASE EXPLAIN) iF YOU WERE PERSONALLY RESPONSIBLE, WOULD YOU RECONIMEND THE EMPLOYMENT OF THIS. "APPLICANT? DA Yes [No (IF NO, PLEASE EXPLAIN) LE Mave hited Fhel ce fore Hi fherenf Oeerisiony feo P'tftet les ine ee org ers apa. des dyperoetle 6 had oe Hes che Vig pessivtfe oboet te coes, He apthn varied Prngupy end ‘dives Pap turhgnicel 00> "ADDITIONAL COMMENT ofenfie : Ther i He acini, wing Codaints RA Tel Streoytes. sounel Di ae COMPANYISCHOOL __M0icne —Macetsinds @ Services NAME (Ploase Print) Bare ADDRESS 07 w) Tomer _Compbut BVT position Préssoeart = Tet (91) ) So: Soy pare 77 Ty a MAILTO: Dielorof School, Mauxy County Goad of Eda ah Sot Wests Stest,coknba TN 30401 ie oven ‘in: Human Resouroae Dept (931) 388-8403, ex. 0118Maury County Public Schools NON - CONFIDENTIAL PROFESSIONAL REFERENCE REQUEST e Tid Eci, mmird, 2. APPLICANT'S FULL NAME: APPLICANT'S ADDRESS: ‘APPLYING FOR PosiTIONAS:_“/eADY4 | IS p7' PAL- PERSON COMPLETING REFERENCE FORM: eft y Wed] eer eg TERE Fase ancrowimmanany [°° [Oran coat] eves erin Sy [ewe cc eat lessee ena tel, fe | n | |e fetes comers] ji, comario (gener cnet, ~ T FES Pangani of nsiion ftes, mera) — aoe —_ —— Sa Fe tama la, Selicontt ve | — PF aaa Pree eto eran fa. Onlommnc ci bt efetl gow Fi oem ceneraLraTine__ “Tach is an excels eT “fee He potion He ts te model eneplaye ant wold be _o elveble OPPORTUNITIES FOR OBSERVING THE CANDIDATE_“Tewk anackeh foc me. fone he ues in cherge of up ard tench on boo to vse wediacl eqeoee nm also did Golles Lp _on pubrents EVER BEEN SUBJECTED TO ANY DISCIPLINARY ACTION, ASKED TO RESIGN, OR No. (IF YES, PLEASE EXPLAIN.) __ FO YOUR KNOWLEDGE, HAS THIS APPLICA EVER FAILED RE-ELECTION? [71 Yes ]-VOU WERE PERSONALLY RESPONSIBLE, WOULD YOU RECOMMEND THE EMPLOYMENT OF “THis APPLICANT? [Yes [No (JF NO, PLEASE EXPLAIN) ‘ADDITIONAL COMMENTS: te — companvrsonoot “TLE (Medico! ‘SIGNATURE ‘ Z NAME (Piease PI ete ler ADDRESS __[50 3. paces vost De Lrakietin W P20 | postion fackoer | VE. Sales TEL (git )_642 - only DATE fz) ya TO: Dost of Scoot Maury Couny Boao Eseaton AY Sot Westen Stes cok, TN 35401 i ‘At Human Resoureae Dept (031) 388-8409, ex. 0118.Y°GOP MIMUNITY COLLEGEuly 14, 2014 ATTN:HUMAN REOURCES DIRECTOR OF SCHOOLS MAURY COUNTY SCHOOLS 501 WEST 8TH STREET COLUMBIA, TN 38401 To Whom It May Concer: This letter is sent to verify that the individual listed below has successfully completed the respective NBRC examination(s) and holds the corresponding credential(s) issued by this Board. “Additionally, the National Respiratory Care Disciplinary Database" has been scanned and no disciplinary actions have been’ found pertaining to this, individual, Individuals who successfully completed the CRT, CPFT, RPFT, NPS or the Sleep Disorders Specialty Examination attained a scaled score of 75 or higher. Individuals who hold the RRT credential successfully completed the Written Registry Examination with a scaled score of 70 or higher and achieved a passing score on the Clinical Simulation Examination or its equivalent. RRTS.are also recognized as CRTs and successfully completed the CRT Examination or its equivalent., The CRT Examination is the equivalent of the CRTT Examination previously administered and the CRT credential is equivalent of the CRT credential previously awarded by the NBRC. Name: _TADE-CUMMINS SSN: redential ‘Valid Thru** Test Date cRT orn7nass RRT - 12/04/1993, Registry # 50596 Please feel free to contact the NBRC Executive Office if you require further information. sincerely, Obeui In. Fink Lori M. Tinkler, MBIA * * Associate Executive Director 'NOTE:. The National Respiratofy Care Disciplinary Database contains reports of final disciplinary proceedings/decisions,. and ‘as such, proceedings/decisions have boen voluntarily reported: by slate agencies and the AARC. Tho NBRC-has no responsibilty and assumes no labilly for the accuracy of the information reported by the state agencios or the AARC. In ‘dition, not all stale agencies may elect fo report. It Is the obligation of the reporting agencies to update any reported infomation. The reported information may have changed and not yet been updated prior to the date of this report. You should fake no action based solely on this report. Any reported disciplinary actions should be independently verified by you by contacting the reporting agency (Le., stale agency, AARC or NBR). “Credentials expire on the above date and will not be recognized as valid if this individual does not complete the Continuing Competency Program requirements. Ifa valid thru date is not fisted, the credential does not expire and the individual is not required to participate in the Continuing Competency Program, National Board for Respiratory Care, nc. 18000 W, 105th Street * Olathe, KS 66061.7543 * 913.895.4900 * Fax 913.895.4650 wuwnbre.org(OMB No. 1615-0047; Bxpires 0831/12 epsetinent of Homeland Security Form I-9, Employment US. Citizenship and innigatonSovces Eligibility Verification ANTI-DISCRIMINATION NOTICE: Itis illegal to diseriminate against work-authorized individuals, Employers CANNOT. city whitch document(s) they will accept from an employes. ‘The refusal fo hire an individual beeause the documents have ‘ature expiration date ay also constitute illegal dserimation, Section 1. Gimployee Information and Verification (10 be completed and signed by employes at tha time employment begins) rietine tat it Mili] ten ne Lugraen at ZA = “Apt. # ‘Dato of Bit (imonthfdayipear) ‘ess (Sree Nena and Wubi) EEE. le =z Soleus a ‘Tae, under penlty of perry, that Tama heck ona ofthe following): ‘Yom aware that federal law provides for Auprisnmont endfor fins fr fe strtemens or Br Ketinnot vt es 7 A nonsitzen ntional of th Unit Site (eo osrtions) use of false documents in connection with the completion ofthis form. {Cy Ati pment reser An) 7 Anatin suthorze to wo (Alea or Admission) __ | sett expizton dt, i opiabe = punter) Renin I LE Onto) PS AZ | coer cnplyee) Tata nr ‘Preparer and/or Translator Certification (ro be completed and signed (Section I inpropared by aporsdh ofr pony eee et hye ced ve completo of somo tte oy bog te ran se Peparwvialatas Samat TT |. “ress Get Name an abr, Clb State, Dip Cade) ils fone) Section’. Employer Reviow and Verleation (To be completed and signed ly employer. Beane one document From Dist OR examine one eget fb aed rm La econ he vest of is Jorn and eoord the le, nab, an expiration date, fany, of the document List A ” OR TistB AND List Z Social Security Card = ee Tasuing eho : i Down —— Bapistian Dat a): Document ‘Bxpiton Date fen): 2 GRIRTINICATION: Tattes, under penalty of perjury, that I have examined the docament(@) preseated by the above-named employes, that ‘the above listed document(s) appear fo be genuine and to relate to the employee named, that the employee began employment on (onth/day/yecr) and that fo the best of my knowledge the employee is authorized fo work In the United States. (State ‘employment agoicler may omit he date the employes began employment) ‘Slagptife of Employer or Authosiajd Representative pPrint Name Tile ancl. manda Atexender flenefite Coordinator ‘Business or Organization Name and. (Sireet Name and Number, City, Stale, Zip Code) — a ei 501 West ath Street Columbia, TN 38401 0. Section 3. Updating and Reverifieation (To be completed and signed by employer ‘H NowNane (applica) Bite af Riv mvahear) (Papptcable) ikeapajes vi gat of we tiation as cpl, ov in ilivaton blow fv io oval ios cree employe worn. Document Tite __Docunat Beaton Dato (fay Tate ade pnally apn, tat oie Besta ng ola ir ples Soran a wot Tae Uae Sats and Wie mnploys proaIeT Aten) the document) Ive examined appear fo be enue au tree fo Ge add. ‘Sighature of Employer or Authorized Representative 7 Tia Fn Teer) = Form FD (ey. TIA) Y PagesMaury CORmpLoyee 1 15 LICENSED Employee Information lot REE . Z Full Name: Lyng aS _ Last - Address: Streot Address, yates ne ae ts a ee Home Phone: —_— __ Alternate Phone: c_) Social Security Number SAMMI river's License # } : SF ve status: martied Race white Sex Mahe spouse'sName: 3’ Lamm fA 7 —_ Spouse's Employer, MLSE __ Spouse’s Work Phone: (B) \PEP-PAAP EDM Job Assignment Head) S/en, Torcher (TE) Birth Date: Work Location Lydeok-~Sohoo/ Fu time_1—< Part Time interim Een cane / a sul Name: La vas at Ti WwW ‘irst ML Last >rimary Phone: —_———a ___Altemate Phone: t Relationship: —§ W7'1e- ae = evened lire Date P77 // Experience Years: Degree: AAS Cl. Level: mount______—_—Base Salary Supplement ‘Total Annual Salary: snsuronce Deductions: Medica! Insurance: Plan Amount per chock: Donia! Insurance Delta Plan 8 ‘Amount por check: Fra Life insurance: cIoNA “Amount por check Vision Insurance ‘Amount per checks Retirement 5% deduction: Yos No