Sample Self-certification Form for UCP 3
This Sample Self-certification for UCP 3 is a form below provided by CDE for the local educational agency (LEA) to complete before its Federal Programs Monitoring (FPM) online review declaring either (A) the LEA had no UCP complaints within a 12-month period or (B) the proper implementation of the UCP investigation process, consistent with the requirements of 3.1, 3.2 of the UCP Instrument. The LEA must upload the Self-certification for UCP 3 on California Accountability and Improvement System (CAIS).
LEA SELF-CERTIFICATION FORM FOR COMPLETION OF AN ONLINE REVIEW OF UCP 3
NAME OF LEA:
TO: CA Dept of Education, Categorical Programs Complaints Management (CPCM) office
SUBJECT: Evidence of proper implementation of the investigation process
Please check A or B below:
A. I certify that the LEA has not received any UCP complaints in the past 12 months.
B. If the LEA has received one or more non-Williams-related UCP complaints with in the past 12 months, a random selection of UCP complaints will be chosen after the upload period and prior to the last day of the on-line review. A CPCM consultant will select individual files to be reviewed by the LEA, and these files will be designated a number (i.e. 1, 2, 3, etc.). The consultant will inform the LEA of the files selected and the LEA will finalize the self-certification by completing the following table and uploading it into CAIS:
UCP 3 Instrument Required ElementsLEAs will be asked to answer Yes or No to the following questions regarding the non-Williams-related UCP complaints chosen by the CPCM consultant:
- 3.1 (b) The six-month timelines were met for filing discrimination, harassment, intimidation or bullying complaints. [EC § 234.1; 5 CCR § 4630.]
- 3.1 (c) The investigative process allowed the complainants and/or representatives the opportunity to present evidence [5 CCR 4631]
- 3.1 (d) A written Decision was sent to the complainant within the 60-day time line or the time was extended by written agreement of the complainant [5 CCR 4631]
- 3.2 (e) The findings of fact based on the evidence gathered [5 CCR 4631]
- 3.2 (f) Conclusion of law [5 CCR 4631]
- 3.2 (g) Disposition of the complaint [5 CCR 4631]
- 3.2 (h) The rationale for such a disposition [5 CCR 4631]
- 3.2 (i) Corrective actions, if any are warranted [5 CCR 4631]
- 3.2 (j) Notice of the complainant’s right to appeal the LEA’s Decision to CDE [EC §§ 234.1, 49013; 5 CCR § 4631.]
- 3.2 (k) Procedures to be followed for initiating an appeal to CDE [EC §§ 234.1, 49013; 5 CCR § 4631]
Name of LEA Superintendent or Designee Position
- Complaints in accordance with CCR, Title 5, Section 4610(b).
- Additional copies of the "LEA Self-Certification of UCP 3" Form may be used by the LEA, when the sample exceeds 3 files. All copies
- would be uploaded onto CAIS by the LEA.
- Districts are not required to upload complaint documents into CAIS as part of the self-certification.