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