Fillable DISCLOSURE STATEMENT APPLICATION FOR EMPLOYMENT, INCLUDING PROVISIONAL EMPLOYMENT

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DISCLOSURE STATEMENT APPLICATION FOR EMPLOYMENT, INCLUDING PROVISIONAL EMPLOYMENT

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1
11/3/15
DISCLOSURE STATEMENT
APPLICATION FOR EMPLOYMENT, INCLUDING PROVISIONAL EMPLOYMENT
Required by the Child Protective Service Law
23 Pa. C.S. Section 6344 (relating to employees having contact with children; adoptive and foster parents)
I swear/affirm that, if being hired on a provisional basis, I have applied for certification through ChildLine, the
Pennsylvania State Police, and the Federal Bureau of Investigation and am submitting a copy of the appropriate
completed request forms to the employer, administrator, supervisor or other person responsible for employment
decisions.
I swear/affirm that, if providing certifications that have been obtained within the preceding 60 months, I have not
been disqualified from employment as outlined below or have not been convicted of an offense similar in nature
to a crime listed below under the laws or former laws of the United States or one of its territories or possessions,
another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former
law of this Commonwealth.
I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse within the past five
(5) years as defined by the Child Protective Services Law.
I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania
consolidated statutes or equivalent crime under the laws or former laws of the United States or one of its
territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign
nation, or under a former law of this Commonwealth.
Chapter 25 (relating to criminal homicide)
Section 2702 (relating to aggravated assault)
Section 2709.1 (relating to stalking)
Section 2901 (relating to kidnapping)
Section 2902 (relating to unlawful restraint)
Section 3121 (relating to rape)
Section 3122.1 (relating to statutory sexual assault)
Section 3123 (relating to involuntary deviate sexual intercourse)
Section 3124.1 (relating to sexual assault)
Section 3125 (relating to aggravated indecent assault)
Section 3126 (relating to indecent assault)
Section 3127 (relating to indecent exposure)
Section 4302 (relating to incest)
Section 4303 (relating to concealing death of child)
Section 4304 (relating to endangering welfare of children)
Section 4305 (relating to dealing in infant children)
Section 5902(b) (relating to prostitution and related offenses)
Section 5903(c) (d) (relating to obscene and other sexual material and performances)
Section 6301 (relating to corruption of minors)
Section 6312 (relating to sexual abuse of children), or an equivalent crime under
Federal law or the law of another state.
I swear/affirm that I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled
substance, drug device and cosmetic act) committed within the past five years.
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11/3/15
I understand that I must be dismissed from employment if I am named as a perpetrator of a founded report of
child abuse within the past five (5) years or have been convicted of any of the crimes listed above.
I understand that if I am being hired on a provisional basis, I am not permitted to work alone with children and
must work in the immediate vicinity of a permanent employee during this provisional employment period.
I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying
employment or participation in a program, activity or service under the Child Protective Services Law as listed
above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee
with written notice not later than 72 hours after the arrest, conviction or notification that I have been listed as a
perpetrator in the Statewide database.
I understand that if the person responsible for employment decisions or the administrator of a program, activity
or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds for
denying employment or participation in a program, activity or service under the Child Protective Services Law,
or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this
section, the person responsible for employment decisions or administrator of a program, activity or service shall
immediately require me to submit current certifications obtained through the Department of Human Services, the
Pennsylvania State Police, and the Federal Bureau of Investigation. The cost of certifications shall be borne by
the employing entity or program, activity or service.
I understand that if I willfully fail to disclose information required above, I commit a misdemeanor of the third
degree and shall be subject to discipline up to and including termination or denial of employment.
I understand that certifications obtained for employment purposes may be used to apply for employment, serve as
an employee, apply to volunteer and serve as a volunteer.
I understand that the person responsible for employment decisions or the administrator of a program, activity or
service is required to maintain a copy of my certifications.
I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing
is a misdemeanor pursuant to Section 4903 of the Crimes Code.
Name: _______________________________Signature:__________________________________
Witness: _______________________________Signature:___________________________________
If the employee is a minor:
Parent/Legal Guardian Name: __________________Signature: _________________________________
Date: _______________________
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DISCLOSURE STATEMENT APPLICATION FOR EMPLOYMENT, INCLUDING PROVISIONAL EMPLOYMENT

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Completed 30 April 2021

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