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
p M p F
COUNTY YOU LIVE IN
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)
Child Care Services Employee
Foster Care Adoption School Employee
Employment with a significant likelihood of regular contact
with children
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).
DPW Employment & Training Program Participant
CY 113 (UF) 6/11
(signature required below)
SIGNATURE OF OIM/CAO REPRESENTATIVE
OIM/CAO PHONE NUMBER
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)
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
AGE
SEX
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
p
p p p
p
p
p
CY 113 (UF) 6/11
VOLUNTARY CERTIFICATION FOR CHILD CARE SERVICES
PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE
PENNSYLVANIA STATE POLICE CLEARANCE
FBI CLEARANCE
SECTION III
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.
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.
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.
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
SECTION II
RESULTS OF HISTORY CHECK
p APPLICANT IS NOT LISTED IN A REPORT OF CHILD ABUSE OR A
REPORT FOR SCHOOL EMPLOYEE.
p APPLICANT IS LISTED IN A REPORT OF CHILD ABUSE OR A
REPORT FOR SCHOOL EMPLOYEE (SEE BELOW).
STATUS OF REPORT DATE OF INCIDENT STATUS OF REPORT DATE OF INCIDENT
1. –
2. –
3. –
4. –
VERIFIER DATE VERIFIER’S SUPERVISOR DATE
DO NOT WRITE IN THIS SECTION - CHILDLINE USE ONLY
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
rst 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 lling in the Social Security number please ll 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 lled 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 Signicant 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 ofce, or
CAO, or the Ofce 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, lling 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 ofce. 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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