Application For Exemption printable pdf download

Application for Exemption from

FBI Background Check for Volunteers

(Under the Child Protective Services Law)

Please read this entire form carefully before completing it. This form is to be used by a Pennsylvania resident who serves or

wants to serve as a volunteer with a program or activity associated with the University of Pittsburgh and seeks exemption from the

requirement to submit a report of federal criminal history record information (FBI background check). Even if granted an exception

from obtaining FBI background checks, you are still required to submit a report of criminal history record information from the

Pennsylvania State Police and a certification from the Department of Human Services concerning child abuse.

Section 1. Personal Information

Name of Volunteer (please print): ______________________________________________________ Date: _____/_____/________

Current Address: _____________________________________________________________________________________________

Number of Years ____________ Months ____________ at this Address*

*If less than 10 years, provide prior Pennsylvania addresses on a separate page.

Volunteer Position: ____________________________________________________________________________________________

Section 2. Instructions

Check the appropriate boxes below. Then, sign the certification under Section 3.

By checking this box, I certify that I have been a resident of Pennsylvania for the entirety of at least the last 10 consecutive years

prior to the date of this application, which is set forth above.

By checking this box, I certify that I have not been convicted of any of the Reportable Offenses listed below.

List of Reportable Offenses

A Reportable Offense enumerated under Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. §6344(c), consists of one or

more of the following:

Provisions of Title 18 of the Pennsylvania Consolidated Statutes (relating to crimes and offenses) or an equivalent crime under the

laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the

Commonwealth of Puerto Rico or a foreign nation, or under a former law of the Commonwealth of Pennsylvania:

Section 3127 relating to indecent exposure

Chapter 25 relating to criminal homicide

Section 4302 relating to incest

Section 2702 relating to aggravated assault

Section 4303 relating to concealing death of a child

Section 2709.1 relating to stalking

Section 4304 relating to endangering welfare of

Section 2901 relating to kidnapping

children

Section 2902 relating to unlawful restraint

Section4305 relating to dealing in infant children

Section 3121 relating to rape

A felony offense under Section 5902(b) relating to

Section 3122.1 relating to statutory sexual assault

prostitution and related offenses

Section 3123 relating to involuntary deviate sexual

Section 5903(c) or (d) relating to obscene and other

intercourse

sexual materials and performances

Section 3124.1 relating to sexual assault

Section 6301 relating to corruption of minors

Section 3125 relating to aggravated indecent assault

Section 6312 relating to sexual abuse of children

Section 3126 relating to indecent assault

An offense designated as a felony under the act of April 14, 1972 (P.L. 233, No. 64), known as “The Controlled Substance, Drug,

Device and Cosmetic Act,” committed within the preceding five-year period.

A founded report within the preceding five-year period in the statewide database maintained by the Department of Human

Services.

Section 3. Certification

I understand that by submitting this completed Volunteer Exemption Form, I swear or affirm that all of the information I have provided

on this application is complete, accurate, true, and correct. I make this declaration subject to the penalties of 18 Pa.C.S. §4904

relating to unsworn falsification to authorities, and that the university may take all actions deemed appropriate based upon false

statements made on this form. I understand that University of Pittsburgh will use the university’s address to receive my clearances.

_____________________________________________________

_____________________________________

Volunteer’s Signature

Date

Application For Exemption

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