Pa Child Abuse History Clearance Form PDF Details

A new form is now available for individuals in Pennsylvania who want to obtain a clear record of their child abuse history. The Pa Child Abuse History Clearance Form can be used by anyone who needs a clean bill of health related to child abuse, including adoption agencies, employers, and school administrators. The process is simple, and the results are instantaneous.

If you'd like to first determine how much time you need to fill in the pa child abuse history clearance form and what number of pages it's got, here is some detailed data that could be of use.

QuestionAnswer
Form NamePa Child Abuse History Clearance Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namespa form child clearance online, pa child abuse check, state of pennsylvania child abuse clearance, child abuse history clearance pa

Form Preview Example

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

COMPLETE SECTION 1 ONLY. Print clearly in ink. Enclose $10.00 money order ONLY, payable to DEPARTMENT OF PUBLIC WELFARE. DO NOT send cash or personal check.

Send to CHILDLINE AND ABUSE REGISTRY, DEPARTMENT OF PUBLIC WELFARE, P.O. BOX 8170 HARRISBURG, PA 17105-8170

APPLICATIONS THAT ARE INCOMPLETE, ILLEGIBLE OR RECEIVED WITHOUT FEE WILL BE RETURNED UNPROCESSED. IF YOU HAVE QUESTIONS CALL 717-783-6211, OR

(TOLL FREE) 1-877-371-5422.

CHILDLINE USE ONLY

DATE RECEIVED BY CHILDLINE

SECTION I

APPLICANT IDENTIFICATION

IN THIS SPACE PRINT APPLICANT’S FULL NAME AND ADDRESS (DO NOT USE INITIALS)

NAME

STREET

CITY, STATE

ZIP CODE

SOCIAL SECURITY NUMBER

AGE

DATE OF BIRTH

DAYTIME PHONE NO.

 

 

 

SEX

COUNTY YOU LIVE IN

 

p M p F

Disclosure of your Social Security number is voluntary. It is sought under 23 Pa.C.S. §§ 6336(a)(1) (relating to Information in statewide central register), 6344 (relating to Information relating to prospective child care personnel), 6344.1 (relating to Information relating to family day-care home residents), and 6344.2 (relating to Information relating to other persons having contact with children). The department will use your Social Security number to search the statewide central register to determine whether you are listed as the perpetrator in an indicated or founded report of child abuse.

PURPOSE OF CLEARANCE (Check ONE block ONLY)

pChild Care Services Employee

p Foster Care p Adoption p School Employee

p Employment with a significant likelihood of regular contact with children

p Volunteers - A copy of your PROCESSED “Request for Criminal Record” (Form SP4-164) must be attached. Out-of-state residents must also attach a copy of their PROCESSED FBI clearance (Form FD-258).

p DPW Employment & Training Program Participant

(signature required below)

PREVIOUS NAMES USED SINCE 1975

(Include Maiden Name, Nicknames, Aliases)

1.(LAST, FIRST, MIDDLE)

2.(LAST, FIRST, MIDDLE)

3.(LAST, FIRST, MIDDLE)

4.(LAST, FIRST, MIDDLE)

5.(LAST, FIRST, MIDDLE)

SIGNATURE OF OIM/CAO REPRESENTATIVE

OIM/CAO PHONE NUMBER

PREVIOUS ADDRESSES SINCE 1975 (Attach additional pages if necessary)

1.

2.

3.

4.

HOUSEHOLD MEMBERS (List everyone who lived with you at any time since 1975 to the present)

NAME (Last, First, Middle) Do not use initials.

RELATIONSHIP

PRESENT

SEX

AGE

 

 

 

1.

2.

3.

4.

5.

6.

I certify that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code).

Applicants are required to show the administrator the original document. Administrators are required to keep a copy of this child abuse history record on file. Any person altering the contents of this document may be subject to civil, criminal or administrative action.

APPLICANT’S SIGNATURE

DATE

CY 113 (UF) 6/11

DO NOT WRITE IN THIS SECTION - CHILDLINE USE ONLY

SECTION II

 

RESULTS OF HISTORY CHECK

p APPLICANT IS NOT LISTED IN A REPORT OF CHILD ABUSE OR A

p APPLICANT IS LISTED IN A REPORT OF CHILD ABUSE OR A

REPORT FOR SCHOOL EMPLOYEE.

 

REPORT FOR SCHOOL EMPLOYEE (SEE BELOW).

STATUS OF REPORT

DATE OF INCIDENT

 

 

1.

 

 

2.

 

 

STATUS OF REPORT

DATE OF INCIDENT

 

 

3.

 

 

4.

 

 

VERIFIERDATEVERIFIER’S SUPERVISORDATE

SECTION III

VOLUNTARY CERTIFICATION FOR CHILD CARE SERVICES

 

 

has requested a certification which includes a clearance of his/her

name against the child abuse, school employee, and criminal history reports.

The results of the child abuse and school employee report clearances are listed in Section II on the reverse side. The results of the criminal history reports are listed below. Out-of-state residents must have criminal history clearance from both the Pennsylvania State Police and the FBI. The voluntary certification may be obtained every two years.

It is the responsibility of parents and guardians to review this information to determine the suitability of the applicant as a substitute caregiver.

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

p Applicant is named as the perpetrator of a founded child abuse or school employee report which occurred in the last five years.

p Applicant is named as the perpetrator of a founded child abuse or school employee report which occurred over five years ago.

p Applicant is named as the perpetrator of an indicated child abuse or school employee report.

p Applicant is not named as the perpetrator of any child abuse or school employee report contained in the Statewide Central Register.

PENNSYLVANIA STATE POLICE CLEARANCE

p Record exists and contains convictions which prohibit hire in a child care position. Report attached. p Record exists, but convictions do not prohibit hire in a child care position. Report attached.

p Record exists, but no convictions are shown. This does not prohibit hire in a child care position. Report attached. p No record exists. Report attached.

FBI CLEARANCE

p Record exists and contains convictions which prohibit hire in a child care position. Report attached. p Record exists, but convictions do not prohibit hire in a child care position. Report attached.

p Record exists, but no convictions are shown. This may not prohibit hire in a child care position. Report attached. p No record exists. Report attached.

p No FBI clearance required.

 

 

 

 

 

VERIFIER

DATE

VERIFIER’S SUPERVISOR

DATE

 

 

 

 

 

CY 113 (UF) 6/11

DIRECTIONS TO COMPLETE THE

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE APPLICATION:

1.Applicants are to complete Section I only.

2.Type or print clearly and neatly in ink only.

3.The space for the applicant’s name must be the applicant’s full legal name. An initial is not acceptable for a irst name. The address listed must be applicant’s current home address. This is also where the results of the clearance will be mailed.

4.The applicant’s Social Security number is voluntary. If illing in the Social Security number please ill in the entire

Social Security number.

5.Age – Fill in the applicant’s current age.

6.Date of Birth – Fill in the applicant’s date of birth (Example: 01/22/1990).

7.Daytime Phone Number – Fill in the number for where the applicant can be reached in the event that there are questions about the information on the application.

8.Sex – Check the appropriate box for male or female.

9.County You Live In – Fill in the name of the county where you reside (this should be the county for the address that the applicant illed in the space on the left of this section).

10.Purpose of Clearance – Do not check more than one block:

a.Check the Child Care box if planning to work in a day care or child care setting.

b.Check the Foster Care box if applying as a prospective foster parent.

c.Check the School Employee box if seeking to have involvement within a school (public, private, vocational, or technical) for employment or volunteer purposes OR check this box if a child abuse clearance is needed due to enrollment in an educational program such as a nursing school or technical program.

d.Check the Adoption Block if in the process or planning to adopt a child.

e.Check Employment With A Signiicant Likelihood of Regular Contact With Children if NONE of the other options relate to why a child abuse clearance is needed.

f.Check the Volunteers box if performing a service (paid or unpaid) for organizations such as Big Brothers/Big Sisters, Boy Scouts, Little League, or churches. As noted on the form, if the Volunteer box is checked, the applicant must also attached A COPY of the RESULTS from their PA State Police Criminal History Record Check. Do not send original criminal record results because the original cannot be returned. If the applicant is not a current Pennsylvania resident, the applicant must also attach a copy of their FBI Criminal History results obtained within the past year.

g.Check the DPW Employment & Training Program Participant box if the applicant is participating in a

Department of Public Welfare employment and training program through a county assistance ofice, or CAO, or the Ofice of Income Maintenance, OIM. The signature AND phone number of the CAO or OIM

representative is required.

11. Previous Names Used Since 1975 - The applicant must list any and all full legal names that they have ever had since 1975. This includes maiden names, aliases and also known as (aka) names.

12. Previous Addresses Since 1975 - List all addresses where the applicant has resided since 1975. The applicant

can attach an additional sheet of paper with all of the addresses listed if necessary. If the applicant cannot remember the exact mailing addresses since 1975, illing in as much information as possible about the location

will be acceptable.

13. Household Members - Include anyone that the applicant lived with since 1975 (parents, guardians, siblings, children, spouse (ex), paramour, friends, etc.). If the applicant was under the age of 18 in 1975 this section must include other household members who lived with the applicant or with whom the applicant lived. Please note the household member’s relationship to the applicant, their age (to the best of your knowledge) and their sex. Applications where this section is left blank will be rejected and returned to the applicant.

14. Applications must be signed and dated. Applications that are not signed and dated will be rejected and returned to the applicant.

15. Enclose a $10.00 money order for each application. No cash or personal checks will be accepted. Agency or business checks are acceptable.

16. Do not send any postage paid return envelopes for us to return your results. Results are issued through an automated system generated mailing process.

Note: Clearance results will be mailed to you within 14 days from the date that the clearance is received in our ofice. Failure to comply

with the above instructions will cause considerable delay in processing the results of an applicant’s child abuse clearance.

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