Cy113 Form - English Child Abuse Clearance - Pennsylvania Child Abuse History Certification Form

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PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

Type or print clearly in ink. If obtaining this certification for non-volunteer purposes or if, as a volunteer having direct volunteer contact with children, you

have obtained a certification free of charge within the previous 57 months, enclose an $8.00 money order or check payable to the PENNSYLVANIA

DEPARTMENT OF HUMAN SERVICES or a payment authorization code provided by your organization. DO NOT send cash.

Certifications for the purpose of “volunteer having direct volunteer contact with children” may be obtained free of charge once every 57 months.

Send to CHILDLINE AND ABUSE REGISTRY, PA DEPARTMENT OF HUMAN SERVICES, P.O. BOX 8170 HARRISBURG, PA 17105-8170.

APPLICATIONS THAT ARE INCOMPLETE, ILLEGIBLE OR RECEIVED WITHOUT THE CORRECT FEE WILL BE RETURNED UNPROCESSED.

IF YOU HAVE QUESTIONS CALL 717-783-6211, OR (TOLL FREE) 1-877-371-5422.

PURPOSE OF CERTIFICATION (Check one box only)

Foster parent

Volunteer having direct volunteer contact with children

Prospective adoptive parent

If purpose is volunteer having direct volunteer contact with chil-

dren, choose SUB PURPOSE:

Employee of child care services

Big Brother/Big Sister and/or affiliate

School employee governed by the Public School Code

School employee not governed by the Public School Code

Domestic violence shelter and/or affiliate

Self-employed provider of child-care services in a family child-care home

Rape crisis center and/or affiliate

An individual 14 years of age or older applying for or holding a paid

Other:

position as an employee with a program, activity, or service

PA Department of Human Services Employment & Training Program

An individual seeking to provide child-care services under contract with a

participant (signature required below)

child care facility or program

An individual 18 years or older who resides in the home of a foster parent

for children for at least 30 days in a calendar year

SIGNATURE OF OIM/CAO REPRESENTATIVE

OIM/CAO PHONE

An individual 18 years or older who resides in the home of a certified or

NUMBER

licensed child-care provider for at least 30 days in a calendar year

An individual 18 years or older, excluding individuals receiving services, who resides in a family living home, community home for individuals with an

intellectual disability, or host home for children for at least 30 days in a calendar year

An individual 18 years or older who resides in the home of a prospective adoptive parent for at least 30 days in a calendar year

AGENCY/ORGANIZATION NAME:

PAYMENT AUTHORIZATION CODE, IF APPLICABLE:

Consent/Release of Information Authorization form is attached. Applicant must fill in the “Other Address” sections. By completing the other address

sections, you are agreeing that the organization will have access to the status and outcome of your certification application.

APPLICANT DEMOGRAPHIC INFO

RMATION (DO NOT USE INITIALS)

FIRST NAME

MIDDLE NAME

LAST NAME

SUFFIX

SOCIAL SECURITY NUMBER

GENDER

DATE OF BIRTH (MM/DD/YYYY)

AGE

Male

Female

___

Not reported

Disclosure of your Social Security number is voluntary. It is sought under 23 Pa.C.S. §§ 6336(a)(1) (relating to information in statewide database), 6344 (relat-

ing to employees having contact with children; adoptive and foster parents), 6344.1 (relating to information relating to certified or licensed child-care home

residents), and 6344.2 (relating to volunteers having contact with children). The department will use your Social Security number to search the statewide

database to determine whether you are listed as the perpetrator in an indicated or founded report of child abuse.

MAILING ADDRESS

OTHER ADDRESS (if Consent/Release of

HOME ADDRESS

(if different from home address)

Information Authorization form is attached)

ADDRESS LINE 1

ADDRESS LINE 2

CITY

COUNTY

STATE/REGION/PROVINCE

ZIP/POSTAL CODE