Form Pdacbc 1 – Fill Out and Use This PDF

VERIFICATION STATEMENT—REQUIRED: By completing this form, I acknowledge I have NOT been a resident of the Commonwealth of Pennsylvania for the past two consecutive years.

______________________________________________

Applicant Signature (Required)

APPLICANT INFORMATION

See Reverse for Acceptable Codes

Street Address Line 1:

Street Address Line 2:

City:				State:	Zip Code:
County of Residence:		Position Applied For:
Daytime Telephone Number:		Evening Telephone Number:
(	)	(	)

EMPLOYER INFORMATION

		Facility Type: (See reverse for acceptable types)	Facility License Number:
(	)

Complete the following ONLY IF facility above is owned by a corporation that requires notification: (address different than above) Corporate Office Name:

Street Address:

Duplication of the original form is acceptable provided only the original (PDACBC-1) form is used and the photocopy is of sufficient quality.

OFFICIAL USE ONLY:

		ACCEPTABLE CODES:
SEX:	“M” = Male	“F” = Female
RACE:	“A” = Asian or Pacific Islander (having origins in any of the original peoples of the Far East, Southeast Asia, Indian subcontinent, or Pacific Islands; includes Pacific Islander, Chinese,
	Japanese, Polynesian, Korean, and Vietnamese)
	“B” = Black (having origins in any of the black racial groups of Africa)
	“I” = American Indian (having origins in any of the original peoples of the Americas and who maintains cultural identification through tribal affiliations or community recognition; includes
	Alaskan native, Eskimo, and American Indian)
	“W” = White (includes Caucasian, Mexican, Latin, Puerto Rican, Cuban, Central/South American, and other Spanish Culture or origin, regardless of race)
	“O”= Other
HEIGHT: expressed in feet & inches (rounded off to the nearest inch) (Example: 5’4”)			WEIGHT: expressed in pounds (rounded off to the nearest pound) (Example: 145 lbs)
EYES:	“BLK” = Black, “HAZ” = Hazel, “BLU” = Blue, “MAR” = Maroon, “GRN” = Green, “BRO” = Brown, “PNK” = Pink, “GRY” = Gray, “MUL” = Multicolored, “XXX” = Unknown
HAIR:	“BAL” = Bald, “RED” = Red, “BLK” = Black, “SDY” = Sandy, “BLN” = Blond, “WHI” = White, “BRO” = Brown, “GRY” = Gray, “XXX” = Unknown

FACILITY TYPES:

● Long-term Care Nursing Facility	● Domiciliary Care Home	● Older Adult Daily Living Center	● Personal Care Home	● Home Health Care Agency
● Dept. of Health Hospice	● Dept. of Health Birth Center	● DPW Family Living Home	● DPW ICF/MR (private and state)	● DPW Comm. Resid. Rehab Svcs
● Dept. of Public Welfare Long Term Structured Residence		● DPW State Mental Hospital	● DPW Community Home for Individuals with MR/Group Home/CLA

FBI BACKGROUND CHECK INSTRUCTIONS:

As defined by Act 169 of 1996 as amended by Act 13 of 1997, when an applicant/employee of a facility mandated by the act (see types above) has not been a resident of the Commonwealth of Pennsylvania for two or more consecutive years (without interruption) immediately preceding the date of application for employment or currently lives out-of-state, in addition to the Pennsylvania State Police Criminal History Check (SP4-164), the applicant/employee will also need to obtain an FBI Criminal History Check. This clearance is obtained by doing the following:

1.Properly complete the PA Department of Aging FBI Fingerprint Card (FD-258)—DO NOT HIGHLIGHT OR BEND/FOLD IN ANY WAY. This form is used to obtain a report from the FBI criminal files. Failure to properly complete the fingerprint card will result in a considerable delay in the processing. Fingerprints cards can be obtained from PA Department of Aging or your local Area Agency on Aging. A photocopy of the FD-258 fingerprint card will not be acceptable.

•Signature of Person Fingerprinted

•Residence of Person Fingerprinted

•Employer and (Employer’s) Address

•Write “Long Term Care Employment, 35 PaSA § 10225.502 [a] [2] in Reason Fingerprinted

•Applicant’s Name (must be printed at top of card—Last, First, then Middle)

•Social Security Number

•Descriptive data (utilize the acceptable codes listed above): Sex, Race, Height, Weight, Eye Color, Hair Color, Place of Birth, Date of Birth

•Complete any other fields that may apply (example: list maiden or other name(s) used in Aliases/AKA)

2.Take the completed card to your nearest PA State Police facility or local police department to have your fingerprints applied to the card. A fee may be charged for this service. The fingerprints must be of sufficient quality that they can be classified by the FBI.

3.The police officer must sign and date the card.

4.EFFECTIVE 9/15/07 - A separate $30.25 processing fee must be enclosed for each FBI card submitted:

•Do NOT send cash, personal checks, or agency checks

•Payments must be in the form of a MONEY ORDER, CASHIER’S CHECK or CERTIFIED CHECK

•Effective 2/1/03 – Payments must be payable to: Commonwealth of Pennsylvania

5.Complete the FBI Background Check Transmittal Form (PDACBC-1)—ON REVERSE. All information must be typed or printed clearly in blue or black ink only. Failure to complete this form will result in a considerable delay in the processing. Duplication of the original form is acceptable provided only the original (PDACBC-1) form is used and the photocopy is of sufficient quality.

6.Mail the fingerprint card, transmittal form, and processing fee in a large manila envelope to the address below (remember to include your return address in the upper left-hand corner of

the envelope):

PA Department of Aging

Criminal History Background Check 555 Walnut St., 5th Floor Harrisburg, PA 17101-1919

Responses from the FBI will be forwarded to the PA Department of Aging after processing to determine if any convictions listed would prohibit the applicant/employee from being employed. The Department of Aging will forward an employment eligibility response to the applicant and the facility.

If you have any questions, please contact the PA Department of Aging at (717) 265-7887, Monday through Friday. “Mandatory Abuse Reporting and Criminal Background Check On-line Training” is

available via our web site www.aging.state.pa.us

Revised 09/07

PDACBC-1