In Process 1 of 2 Pennsylvania’s State System of Higher Education Volunteer Exemption from FBI Background Check (Under the Child Protective Services Law) Please read this entire form carefully before completing it. This form is to be used by a Pennsylvania resident who serves or wants to serve as a volunteer with a program or activity associated with Pennsylvania’s State System of Higher Education or one of its universities and seeks exemption from the requirement to submit a report of federal criminal history record information (FBI background check). You are still required to submit a report of criminal history record information from the Pennsylvania State Police and a certification from the Department of Human Services concerning child abuse. Section 1. Personal Information Name of Volunteer: _________________________________________________ Date: ________________ Current Address: _______________________________ City: ________________ State: _________ Zip: __________ Number of Months ____________ Years ____________ at this Address* *If less than 10 years, provide prior Pennsylvania addresses on a separate page. Volunteer Position: __________________________________________________ Section 2. Instructions Check the appropriate boxes below. If you can check both boxes you are exempt from getting the FBI fingerprint clearance. If you can’t check both boxes you must register for FBI fingerprinting. Then, sign the certification under Section 3. By checking this box, I certify that I have been a resident of Pennsylvania for the entirety of at least the last 10 consecutive years prior to the date of this application, which is set forth above. By checking this box, I certify that I have not been convicted of any of the Reportable Offenses listed below. 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 Docusign Envelope ID: DEAEB2A8-63E7-4877-B042-5014B6911E48
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