Attachment 1 This form has been developed by Pennsylvania’s State System of Higher Education, pursuant to Pennsylvania’s Child Protective Services Law, 23 Pa.C.S. § 6301 et seq. February 5, 2015 1 of 2 Pennsylvania’s State System of Higher Education Background Clearance Certification for Provisional Employment or Volunteering (Under the Child Protective Services Law) Please read this entire form carefully before completing it. This form is to be used only for provisional volunteers and employees who meet the criteria set forth in Procedure/Standard Number 2015-21. In certain limited circumstances, current employees/volunteers may need to complete this form. Section 1. Personal Information Full Legal Name: __________________________________________________ Date of Birth: ____/____/_______ Any former names or aliases by which you have been identified: _____________________________________________ Section 2. Instructions Please submit this form to Kutztown University, P.O. Box 730, Kutztown, PA 18052. If you have any question about whether to report an offense, you should report it. Failure to report may result in disqualification for employment. 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: (i) 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: Chapter 25 relating to criminal homicide Section 2702 relating to aggravated assault Section 2709.1 relating to stalking Section 2901 relating to kidnapping Section 2902 relating to unlawful restraint Section 3121 relating to rape Section 3122.1 relating to statutory sexual assault Section 3123 relating to involuntary deviate sexual intercourse Section 3124.1 relating to sexual assault Section 3125 relating to aggravated indecent assault Section 3126 relating to indecent assault Section 3127 relating to indecent exposure Section 4302 relating to incest Section 4303 relating to concealing death of a child Section 4304 relating to endangering welfare of children Section 4305 relating to dealing in infant children A felony offense under Section 5902(b) relating to prostitution and related offenses Section 5903(c) or (d) relating to obscene and other sexual materials and performances Section 6301 relating to corruption of minors Section 6312 relating to sexual abuse of children A felony offense under section 2718 (relating to strangulation) A felony offense under section 3301 (relating to arson and related offenses) An offense under 18 U.S.C. § 2261 (relating to interstate domestic violence) or § 2262 (relating to interstate violation of protection order) the attempt, solicitation, or conspiracy to commit any of the above
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