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 Signicant 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 ofce, or
CAO, or the Ofce 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 ofce. Failure to comply
with the above instructions will cause considerable delay in processing the results of an applicant’s child abuse clearance.
