Pa Dhs Form - Consent/release Of Information Authorization Form For The Pennsylvania Child Abuse History Certification Page 2

Please send my certification result(s) to:

Agency Name:

Agency Street Address:

Agency City, State, Zip Code:

Date

Applicant’s Signature

As the agency/organization representative, I understand that, except for the subject of a report,

persons who receive this information are subject to the confidentiality provisions of the CPSL

and 55 Pa. Code, Chapter 3490 and are required to ensure the confidentiality and security

of the information and are liable for civil and criminal penalties for releasing information

to persons who are not permitted access to this information. I agree to receive and maintain

this information in accordance with these requirements.

Date

Agency’s Representative Signature

NOTE: IF THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION FORM/APPLICATION (CY 113) IS NOT COMPLETED ACCURATELY

OR IF IT IS INCOMPLETE, THE CY 113 WILL BE RETURNED TO THE APPLICANT AND NOT BACK TO A THIRD PARTY.

Revised 12-29-15

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CY 999 3/16

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