Cy113 Form - English Child Abuse Clearance - Pennsylvania Child Abuse History Certification Form Page 4
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4• Check the box for 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 if
you are an adult household member in this setting and require certification.
• Check the box for individual 18 years or older who resides in the home of a prospective adoptive parent for at least 30 days in a
calendar year if you are an adult household member in this setting and require certification.
• Check the volunteer having direct volunteer contact with children box if applying for the purpose of volunteering as an adult for an
unpaid position as a volunteer with a child-care service, a school, or a program, activity or service as a person responsible for the child’s
welfare or having direct volunteer contact with children. In addition, check the box of one of the organizations listed, i.e. Big Brother/Big
Sister, domestic violence shelter, rape crisis center. If you are NOT applying for a volunteer in one of the organizations listed, please check
the other box and write the name of the organization in the space provided.
• Check the PA Department of Human Services employment & training program participant box if you are applying for the purpose
of participating in a PA Department of Human Services employment and training program through a county assistance office (CAO) or
the Office of Income Maintenance (OIM). The signature AND phone number of the CAO or OIM representative is required. If there is no
signature and no phone number, your application will be rejected and returned to you.
• If you were provided a “PAYMENT AUTHORIZATION CODE” by an organization, please provide the agency/organization name in the
space provided and the payment authorization code in the space provided.
• Please check the CONSENT/RELEASE OF INFORMATION box if you included a payment code in the space above and attached the
completed Consent/Release of Information Authorization form to your Pennsylvania Child Abuse History Certification application when
you mail it to our office. The Consent/Release of Information Authorization form allows the department to send your results to a third party.
If the Consent/Release of Information Authorization form is NOT attached to the certification application, the results WILL be mailed to the
applicant’s home address and not to the third party.
Applicant Demographic Information:
• Name - Include the applicant’s full legal name. Initials are not acceptable for a first name. If your full legal name is an initial, please
provide supporting documentation along with your certification application.
• Social Security number - Include the applicant’s social security number. A social security number is voluntary; HOWEVER, PLEASE
NOTE THAT APPLICATIONS THAT DO NOT INCLUDE SOCIAL SECURITY NUMBERS MAY TAKE LONGER TO BE PROCESSED.
• Gender - Please check one box.
• Date of birth - Fill in the applicant’s date of birth (Example: 01/22/1990).
• Age - Fill in the applicant’s current age.
Address:
• The address listed must be the applicant’s current home address. This is also where the results of the certification will be mailed, unless
otherwise noted. If the different mailing address box is checked and a mailing address is provided in the “different” mailing address
column, the results will be mailed to the “mailing” address and not the “home” address. Note: If the consent/release of information box is
checked and an “other” address is provided, the results will be mailed to the “other” address.
Contact Information:
• Please provide your home, work or mobile telephone number. Fill in the number where the applicant can be reached in the event that
there are questions about the information on the application.
• Please provide an email address. By providing an email address, you are consenting to ChildLine contacting you by email in the event
that you cannot be reached by phone. NO CONFIDENTIAL INFORMATION WILL EVER BE SHARED OR PROVIDED IN AN EMAIL
FROM OUR OFFICE.
Previous Names Used Since 1975:
• The applicant must list any and all full legal names that they have ever had since 1975. This includes maiden names, nicknames, aliases
and also known as (aka) names.
Previous Addresses Since 1975:
• List all addresses where the applicant has resided since 1975. The applicant can attach an additional sheet of paper with all of the
addresses listed if necessary. If the applicant cannot remember the exact mailing addresses since 1975, filling in as much information as
possible about the location is acceptable.
Household Members:
• Include anyone that the applicant lived with since 1975 (parents, guardians, siblings, children, spouse (ex), paramour, friends, etc.). In
addition, include the household member’s relationship to the applicant, their age (to the best of your knowledge) and their gender. If the
applicant was under the age of 18 in 1975, this section MUST include the applicant’s PARENT(S) or GUARDIAN(S). If this section is left
blank, the application will be rejected and returned to the applicant.
Signature:
• Applications MUST be signed and dated. Applications that are not signed and dated will be rejected and returned to the applicant.
CHILDLINE USE ONLY:
• Please DO NOT WRITE in this section. This is for CHILDINE staff only.
Additional Information:
Applicants can visit https:// for more information about submitting the child abuse certification online or to
register for a business/organization account.
CY 113 12/15
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