The Pennsylvania Child Abuse History Clearance form is a critical document used to certify an individual's clearance of any history of child abuse. This process is essential for anyone looking to work or volunteer in positions that involve direct contact with children, such as teaching, foster care, and various childcare services. It ensures the safety of children by thoroughly vetting the backgrounds of those entrusted with their care and supervision.
Ensuring the safety and well-being of children is a paramount concern in Pennsylvania, especially when it comes to those in positions of trust and authority. The Pennsylvania Child Abuse History Certification form serves as a crucial tool in this effort, meticulously designed to screen individuals seeking to work or volunteer in capacities that involve direct contact with children. Whether you're a prospective foster or adoptive parent, an employee or volunteer at a child care service, a school staff member, or even a resident in a household that provides care for children, completing this form is mandatory. It requires applicants to provide detailed personal information, past addresses, and the names of anyone they have lived with since 1975 to ensure a thorough background check can be conducted. With a fee of $13 for non-volunteer purposes—but a provision allowing free certification every 57 months for volunteers—the process is both accessible and efficient. The application, once completed, is sent to the CHILDLINE and Abuse Registry under the Pennsylvania Department of Human Services, ensuring a comprehensive vetting process. The importance of this certification cannot be overstated, as it aims to protect the most vulnerable by preventing those with a history of child abuse from assuming roles where they could potentially cause harm.
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 $13.00 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-
Employee of child care services
dren, choose SUB PURPOSE:
School employee governed by the Public School Code
Big Brother/Big Sister and/or affiliate
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 INFORMATION (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.
HOME ADDRESS
MAILING ADDRESS
OTHER ADDRESS (if Consent/Release of
(if different from home address)
Information Authorization form is attached)
ADDRESS LINE 1
ADDRESS LINE 2
CITY
COUNTY
STATE/REGION/PROVINCE
ZIP/POSTAL CODE
COUNTRY
Different mailing address
ATTENTION
CONTACT INFORMATION
HOME TELEPHONE NUMBER
WORK TELEPHONE NUMBER
MOBILE TELEPHONE NUMBER
EMAIL (By submitting an email contact, you are agreeing to ChildLine contacting you at this address.)
CY 113 12/15
PREVIOUS NAMES USED SINCE 1975 (Include maiden name, nickname and aliases.)
First
Middle
Last
Suffix
1.
2.
3.
4.
5.
PREVIOUS ADDRESSES SINCE 1975 (Please list all addresses since 1975, partial address acceptable; attach additional pages if necessary.)
6.
7.
8.
9.
10.
HOUSEHOLD MEMBERS
(Please list everyone who lived with you at any time since 1975 to present.
Please include parent, guardian or the person(s) who raised you; attach additional pages as necessary.)
Name (First, Middle, Last)
Relationship
Present
Gender
Age
Parent
Guardian
person(s) who raised you
I affirm that the above information is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code). If I selected volunteer, I understand that I can only use the certificate for volunteer purposes.
APPLICANT’S SIGNATURE
DATE
CHILDLINE USE ONLY
DATE RECEIVED BY CHILDLINE
SUFFICIENT PAYMENT INFORMATION RECEIVED YES NO
VALID PAYMENT AUTHORIZATION CODE WAIVED (supervisor initials) ___________
CERTIFICATION ID #
INSTRUCTIONS TO COMPLETE THE
PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION APPLICATION:
General:
•Type or print clearly and neatly in ink only.
•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 $13.00 money order or check for each application. No cash will be accepted. Personal, agency, or business checks are acceptable. Certifications for the purpose of “volunteer having direct volunteer contact with children” may be obtained free of charge once every 57 months. If no payment is enclosed for a non-volunteer purpose, you must provide a payment authorization code, otherwise your application will be rejected and returned to you.
•DO NOT SEND POSTAGE PAID RETURN ENVELOPES for us to return your results. Results are issued through an automated system generated mailing process.
•Certification results will be mailed to you within 14 days from the date the certification application is received at the ChildLine and Abuse
Registry.
•Failure to comply with the instructions will cause considerable delay in processing the results of an applicant’s child abuse history certification application.
Purpose of Certification - Do not check more than one box:
•Check the foster parent box if applying for purposes of providing foster care.
•Check the prospective adoptive parent box if applying for the purpose of adoption.
•Check the employee of child care services box if applying for the purpose of child care services in the following:
-Child day care centers; group day care homes; family day care homes; boarding homes for children; juvenile detention center services or programs for delinquent or dependent children; mental health services for children; services for children with intellectual disabilities; early intervention services for children; drug and alcohol services for children; and day care services or other programs that are offered by a school.
•Check the school employee governed by the Public School Code box if you are a school employee who is required to obtain background checks pursuant to Section 111 of the Public School Code and will continue to be required to obtain background checks prior to employment in accordance with that section and on the periodic basis required by Act 153.
•Check the school employee not governed by the Public School Code box if you are a school employee not governed by Section 111 of the Public School Code, but covered by Act 153 (pertaining to school employees in institutions of higher education).
Definition of school employee: A school employee is defined as an individual who is employed by a school or who provides a program, activity or service sponsored by a school. The term does not apply to administrative or other support personnel unless they have direct contact with children.
Definition of school: A facility providing elementary, secondary or postsecondary educational services. The term includes the following:
(1)Any school of a school district.
(2)An area vocational-technical school.
(3)A joint school.
(4)An intermediate unit.
(5)A charter school or regional charter school.
(6)A cyber charter school.
(7)A private school licensed under the act of January 28, 1988 (P.L.24, No. 11), known as the Private Academic Schools Act.
(8)A private school accredited by an accrediting association approved by the state Board of Education.
(9)A non-public school.
(10)An institution of higher education.
(11)A private school licensed under the act of December 15, 1986 (P.L. 1585, No. 174), known as the Private Licensed Schools Act.
(12)The Hiram G. Andrews Center.
(13)A private residential rehabilitative institution as defined in section 914.1-A(c) of the Public School Code of 1949.
•Check the self-employed provider of child-care services in a family child-care home if providing child care services in one’s home
(other than the child’s own home) at any one time to four, five, or six children who are not relatives of the caregiver.
•Check the individual 14 years of age or older who is applying for or holding a paid position as an employee box if the employment is with a program, activity, or service, as a person responsible for the child’s welfare or having direct contact with children: Applying as an employee who is responsible for the child’s welfare or having direct contact (providing care, supervision, guidance, or control to children or having routine interaction with children) in any of the following in which children participate and which is sponsored by a school or public or private organization:
-A youth camp or program;
-A recreational camp or program;
-A sports or athletic program;
-A community or social outreach program;
-An enrichment or educational program; and
-A troop, club, or similar organization
•Check the individual seeking to provide child care services under contract with a child care facility or program box if you are providing child care services as part of a contract or grant funded program.
•Check the box for individual 18 years or older who resides in the home of a foster 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 box for individual 18 years or older who resides in the home of a certified or licensed child-care provider 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, 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://www.compass.state.pa.us/CWIS for more information about submitting the child abuse certification online or to register for a business/organization account.
Filling out the Pennsylvania Child Abuse History Certification form is an important step in safeguarding the well-being of children across the state. It is a process that demands attention to detail to ensure accuracy and completeness. Whether you are applying as a volunteer, foster parent, or in any other capacity that involves direct contact with children, understanding how to properly complete the form is paramount. The following steps will guide you through the process, helping you provide all the necessary information to ensure your application is processed efficiently and accurately.
After successfully submitting your form, expect to receive your certification results within 14 days. Remember, any omission or error in your application can lead to delays, so take the time to fill out each section carefully. This proactive measure plays a crucial role in ensuring the safety and security of children in Pennsylvania, reinforcing the collective responsibility to protect the most vulnerable members of our community.
Who needs to complete the Pennsylvania Child Abuse History Certification?
The Pennsylvania Child Abuse History Certification is needed by individuals in various roles, including foster parents, prospective adoptive parents, employees of child care services, school employees (both governed and not governed by the Public School Code), and volunteers having direct contact with children. It's also required for self-employed providers of child-care services in a family child-care home, individuals seeking to work with children under a contract with a child care facility or program, and adults living in the home of a foster parent, certified or licensed child-care provider, or a prospective adoptive parent for at least 30 days in a calendar year.
How much does it cost to get the Pennsylvania Child Abuse History Certification?
For most applicants, there is a $13.00 fee, payable by check or money order to the PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES. This fee is required unless the certification is for a volunteer having direct volunteer contact with children, which can be obtained free of charge once every 57 months. If a certification is requested for volunteer purposes and the applicant has not exceeded the 57-month threshold for a free request, no fee is required.
How can the application for the Pennsylvania Child Abuse History Certification be submitted?
The application can be completed and mailed to the CHILDLINE AND ABUSE REGISTRY, PA DEPARTMENT OF HUMAN SERVICES at the provided address. The form must be filled out clearly and legibly in ink. Applications that are incomplete, illegible, or not accompanied by the correct fee will be returned unprocessed. Additionally, applicants have the option to submit their application online via the Child Welfare Information Solution (CWIS) portal.
How long does it take to receive the results of the certification?
Results are generally mailed to the applicant within 14 days from the date the certification application is received by the ChildLine and Abuse Registry. It's important to ensure that the application is complete and the mailing address is correct to avoid delays in processing and receiving the certification.
Is it necessary to provide a Social Security number on the application?
Providing a Social Security number is voluntary but highly recommended, as it helps expedite the search in the statewide database to determine if an individual is listed as the perpetrator in an indicated or founded report of child abuse. Applications that do not include a Social Security number may take longer to process. The Department of Human Services uses Social Security numbers solely for the purpose of accurately identifying individuals in the certification process.
When filling out the Pennsylvania Child Abuse History Certification form, individuals often make mistakes that can delay the processing of their applications or cause them to be returned unprocessed. Here are five common mistakes:
Not including the correct fee or payment authorization code: For non-volunteer purposes or if a volunteer certification was obtained for free within the previous 57 months, failing to enclose a $13.00 money order or check, or a valid payment authorization code, can result in the application being returned.
Choosing more than one purpose: Applicants must check only one box to indicate the purpose of the certification. Selecting multiple purposes can cause confusion and delay the processing of the application.
Using initials instead of full legal names: The form requires the applicant's full legal name. Utilizing initials or not providing the full name can lead to processing delays.
Omitting previous names or addresses: Not listing all previous names used since 1975, including maiden names, nicknames, and aliases, as well as not listing all previous addresses since 1975, can hinder the thoroughness and accuracy of the background check.
Failing to sign and date the application: An unsigned or undated application is incomplete and will be returned to the applicant, leading to further delays in processing.
Overall, ensuring the accuracy and completeness of the application by avoiding these mistakes is crucial for a smooth process in obtaining the Pennsylvania Child Abuse History Certification.
The Pennsylvania Child Abuse History Certification is a critical document for individuals seeking to work or volunteer in positions involving direct contact with children. This document ensures the safety of children by verifying that an applicant has no history of child abuse. However, obtaining this certification is usually part of a broader screening process. Various other forms and documents are often required alongside the Pennsylvania Child Abuse History Certification to complete this comprehensive check.
In addition to the Pennsylvania Child Abuse History Certification, these documents play a crucial role in the comprehensive vetting process. Together, they help organizations make informed decisions about an individual's suitability for roles involving care, supervision, guidance, or control of children. Ensuring the safety and well-being of children is of utmost importance, and thorough screening is a fundamental part of achieving this goal.
The Pa Child Abuse History Clearance form is similar to several other documents required by states or organizations to ensure the safety and well-being of children. These documents often serve to vet individuals who will be working with or around children in various capacities. Each of these documents has specific purposes but shares the critical goal of protecting children from potential harm.
The first document similar to the Pa Child Abuse History Clearance form is the Federal Bureau of Investigation (FBI) Criminal Background Check. Like the Pennsylvania form, an FBI background check is often required for jobs that involve working with vulnerable populations, including children. While the Pennsylvania Child Abuse History Clearance specifically looks into records of child abuse, the FBI Criminal Background Check provides a more comprehensive criminal history. It covers state and federal records, including but not limited to, histories of violent crimes, theft, and other criminal activities that might not be directly related to child abuse. The FBI check requires fingerprinting to identify and pull records accurately, providing a nationwide check rather than limiting to Pennsylvania state records.
Similarly, the State Police Criminal Record Check shares objectives with the Pennsylvania Child Abuse History Clearance. Required for many of the same reasons—such as employment in schools, child care, and foster care—this check focuses on a person's criminal history within a specific state. Unlike the comprehensive national search conducted in an FBI background check, state police checks are limited to any crimes recorded in the state's databases. This often includes arrests, convictions, and pending charges. Although it doesn't specifically target child abuse records, it's a vital component in forming a comprehensive understanding of an individual's background when combined with the child abuse history clearance.
When completing the Pennsylvania Child Abuse History Certification form, there are several dos and don'ts to keep in mind to ensure the process is handled efficiently and accurately. Below is a list of recommendations to guide applicants through this important process.
By following these recommendations, applicants can navigate the certification process more smoothly, ensuring their application is processed in a timely and efficient manner.
There are several common misconceptions about the Pennsylvania Child Abuse History Certification form that need to be clarified:
Understanding the specifics of the Pennsylvania Child Abuse History Certification form is crucial for a smooth and accurate application process. Dispelling these misconceptions helps applicants meet all requirements and avoid potential delays or rejections.
Filling out the Pennsylvania Child Abuse History Certification form is a crucial step for many individuals working or volunteering in positions that involve direct contact with children. Here are 10 key takeaways to ensure the process is completed accurately and efficiently.
By carefully adhering to these guidelines, applicants can ensure their Pennsylvania Child Abuse History Certification form is processed smoothly, aiding in their journey to work or volunteer with children.
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