Get Child Abuse Clearance

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE CHILDLINE USE ONLY COMPLETE SECTION 1 ONLY. Print clearly in ink. 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. P Applicant is named as the perpetrator of a founded child abuse or school employee report which occurred in the last five years. ago. Statewide Central Register. PENNSYLVANIA STATE POLICE CLEARANCE p Record exists and contains convictions which prohibit hire in a child care position. Report attached. p No record exists. RELATIONSHIP PRESENT 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. 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. Check the Adoption Block if in the process or planning to adopt a child. e. Check Employment With A Significant 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. 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 RESULTS OF HISTORY CHECK p APPLICANT IS NOT LISTED IN A REPORT OF CHILD ABUSE OR A REPORT FOR SCHOOL EMPLOYEE. STATUS OF REPORT p APPLICANT IS LISTED IN A REPORT OF CHILD ABUSE OR A DATE OF INCIDENT VERIFIER VERIFIER S SUPERVISOR 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. 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 Significant 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.