Pennsylvania Child Abuse History Clearance Forms printable pdf download

Pennsylvania Child Abuse History Clearance Forms

Pennsylvania Child Abuse History Clearance Instructions

Please read the instructions prior to downloading the form. To request a supply of the forms, please call (717)783-6211.

1. Type or print clearly and neatly in ink Section I only.

2. Address must be Applicant's current home address.

3. All information must be completed in full. (The form asks for all previous names, addresses, and household

members since 1975). This information must be provided to the best of your knowledge and belief. If

necessary, attach additional pages.

4. Application must be signed.

5. Enclose a $10.00 money order for each application. No cash or personal checks accepted. Agency or business

checks are acceptable.

6. Do not send any postage paid return envelopes.

7. Application should be placed in a business-sized or larger envelope prior to mailing.

8. One block must be checked for Purpose for Clearance. Do not check more than one block.

A. Check the Volunteer Block if performing a service (paid or unpaid) for organizations such as Big

Brothers/Big Sisters, Boy Scouts, Little League or churches. A copy of your Criminal Record Check

results obtained within the past year must be attached. Do not send original Criminal Record results. If

you are not a Pennsylvania resident, you must also attach a copy of your FBI results obtained within the

past year. This block should not be checked for anyone volunteering in schools.

B. Check the School Block if seeking to have involvement within a school (public, private vocational,

technical, nursing) for any reason.

C. Check the Foster Care Block if applying for foster parenting or custody of a child.

D. Check the Adoption Block if in the process or planning to adopt a child.

E. Check the Child Care Block if planning to work in a day care setting or if all other blocks do not apply.

F. Check the CWEP Block if you are participating in a Department of Public Welfare training program. The

signature and phone number of the County Assistance Representative is required.

Clearance results will be mailed to you within 14 days from the date that the clearance is received in our office. There

will be no replacements after 90 days. Failure to comply with the above instructions will cause considerable delay.

Please contact the following for applicable criminal history requests:

PA Criminal Record Checks (SP4 164): (717) 783-9973

FBI Cards for School Employees (FD 258): (717) 783-3750

If you have trouble accessing this information you may obtain an alternative format by contacting the Office of

Children Youth and Families at (717) 783-6211. You can also call (717) 783-6211 for clearance requests.

Pennsylvania Child Abuse History Clearance Form (CY-1 13)

Pennsylvania State Police Request for Criminal Record Check Form (SP4- 164) Last modified on: September 11,

2006

Revised 9/14/09

Form No. HR-005

Pennsylvania Child Abuse History Clearance Forms