PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE


 

 

 

 

 

 


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)

 

SOCIAL SECURITY NUMBER

AGE

DATE OF BIRTH

DAYTIME PHONE NO.

SEX

 M     F

COUNTY YOU LIVE IN

 

 
NAME STREET

CITY, STATE ZIP CODE

 

 

 

 

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)                                                 PREVIOUS NAMES USED SINCE 1975 (Include Maiden Name, Nicknames, Aliases)


   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

(signature required below)

 

 

 

 

SIGNATURE OF OIM/CAO REPRESENTATIVE                             OIM/CAO PHONE NUMBER


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

 

1.

2.

3.

4.

5.

6.


 

SEX


 

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