Pennsylvania Child Abuse History Clearance Forms (Page 4 of 4) in pdf

Pennsylvania Child Abuse History Clearance Forms Page 4

DO NOT WRITE IN THIS SECTION

CHILDLINE USE ONLY

SECTION III

VOLUNTARY CERTIFICATION FOR CHILD CARE SERVICES

has requested a certification which includes a clearance of

his/her name against the child abuse, school employee, and criminal history reports.

The results of the child abuse and school employee report clearances are listed in Section II on the

reverse side. The results of the criminal history reports are listed below. Out-of- state residents

must have criminal history clearance from both the Pennsylvania State Police and the FBI. The

voluntary certification may be obtained every two years.

It is the responsibility of parents and guardians to review this information to determine the

suitability of the applicant as a substitute caregiver.

PENNSYLVANIA CHILDABUSE HISTORYCLEARANCE

Applicant is named as the perpetrator of a "Founded" child abuse or school employee report

which occurred in the last five years.

Applicant is named as the perpetrator of a "Founded" child abuse or school employee report

which occurred over five years ago.

Applicant is named as the perpetrator of an "Indicated" child abuse or school employee report.

Applicant is not named as the perpetrator of any child abuse or school employee report

contained in the Statewide Central Register.

PENNSYLVANIA STATE POLICE CLEARANCE

Record exists and contains convictions which prohibit hire in a child care position. Report

attached.

Record exists, but convictions do not prohibit hire in a child care position. Report attached.

Record exists, but no convictions are shown. This does not prohibit hire in a child care

position. Report attached.

No record exists. Report attached.

FBI CLEARANCE

Record exists and contains convictions which prohibit hire in a child care position. Report

attached.

Record exists, but convictions do not prohibit hire in a child care position. Report attached.

Record exists, but no convictions are shown. This may not prohibit hire in a child care

position. Report attached.

No record exists. Report attached.

No FBI clearance required.

VERIFIER

DATE

VERIFIER'S SUPERVISOR

0 3 4 6 0 0

C Y 1 1 3 - 1 2 / 9 9

Pennsylvania Child Abuse History Clearance Forms Page 4