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  • October 1, 2013 - September 30, 2014

    Child Care Forms

    New FBI Clearance Required

    All of the following individuals are now required to submit Federal Bureau of Investigation criminal history background checks in addition to child abuse and Pennsylvania State Police background checks as a condition of employment/approval:

    • Prospective foster and adoptive applicants and their adult household members;
    • Individuals who want to operate child care facilities;
    • Individual who want to work in child care facilities;
    • Individuals seeking to operate child care services;
    • Individuals applying for employment with a significant likelihood of regular contact with children;
    • Self-employed family day care providers;
    • Family day care home household members age 18 and over who live in the home at least 30 days in a calendar year;
    • Community Rehabilitation Residential or CRR host home families; and
    • Respite provider families.

    Current employees and providers of child care facilities are not required to obtain FBI clearances as a condition of continued employment by the same legal entity or continued operation. Employees may transfer to another child care service under the same organization without having to obtain FBI clearances as a condition of transferring. This follows the same procedures already in law under the Child Protective Services Law.

    An employee hired on a provisional basis will have to submit proof of application for an FBI criminal history clearance in addition to the current provisional hiring requirements in the Child Protective Services Law. The length of the provisional hire period is unchanged. Pennsylvania residents may be hired on a provisional basis for a single period of no more than 30 days. Out-of-state residents may be hired on a provisional basis for a single period of no more than 90 days.

    Prospective employees applying to engage in occupations with a significant likelihood of regular contact with children, in the form of care, guidance, supervision or training must obtain background checks as a condition of employment. These individuals, including but not limited to social service workers, psychiatrists, hospital personnel, counselors and therapists, librarians and doctors. Any additional requirements surrounding provisional hiring periods or licensing implications related to the completion of background checks for these individuals should be directed to the appropriate licensing entity.

    The Department of Public Welfare is utilizing Cogent Systems to process fingerprint-based FBI record checks. The fingerprint based background check is a multiple step process. The Cogent Systems Web site, allows individuals to apply online, as well as provide detailed information regarding the application process. The cost of obtaining the FBI criminal record check is $27.50.

    More information about this new requirement can be found by search for Bulletin #3490-08-03 in our Bulletin Search.

    Other Child Care Forms: (all forms are PDF downloads)

    Application for Certificate of Compliance for Center Group
    Application for Certificate of Registration for Family
    CPSL-Provisional Hiring Disclosure Statement
    Child Care Emplyoment Verification Form
    CD 208 - Child Service Report
    CD 51 (formerly CY 51) Child Health Assessment
    CD-322 - Staff Health Assessment
    CY 142 - Day Care Staff Data Sheet
    CY 321 - Day Care Agreement
    CY 862 - Medication Log
    CY 863 - Verbal Request for Release of Child
    CY 864 - Fire Drill Log
    CY 866 - Incident Report Form
    CY 867 - Emergency Contact/Parental Consent Form
    CY 113 - Pennsylvania Child Abuse History Clearance
    SP 4-164 - Request for Criminal Record Check
    PW 29A - Day Care Services Enrollment/Attendance Record 
    Staff Data Worksheet


    Additional questions may be directed to the appropriate Regional Office of Child Development:

    North Central Region: Harrisburg (717) 772-7078 or (800) 222-2117 
    Scranton (570-963-4371 or (800) 222-2108
    Southeast Region (215) 560-2541 or (800) 346-2929
    Western Region (412) 565-5183 or (800) 222-2149