Centralized Clearance Check 04-27-2026.pdf

Attachment 4-A

CENTRALIZED CLEARANCE CHECK INFORMATION REQUEST

Please type the following information. Enter N/A in any space that does not apply. All information shall be kept confidential but it must be provided in order to complete a clearance check. Omission of pertinent information or the falsifacation of information shall be grounds for immediate disapproval or possible criminal prosecution. It is the responsibility of the requestor to initiate renewal of all clearances. Applicant shall submit this request form to the facility or respective Central Office moderator. Use additional sheets if necessary.

SECTION “A” (APPLICANT) The following two questions MUST be filled out:

• Have you ever worked in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution? Yes No

• Have you ever been civilly or administratively adjudicated, convicted, or otherwise disciplined for committing an act of sexual abuse or sexual harassment in the workplace or community? Yes No

Type of Clearance: Initial Clearance Request Renewal Request Category:

Agency Temp Services Contract Service Provider Intern/Extern Organization Reentry Services Vendor Volunteer Program

• If I am an Official Visitor (select one): Government PA Prison Society

• If I am a Public Visitor (select one): Ministry Criminal Justice Entertainment, Sports, Activities, Guest Speaker, Other (explain): ______________________________________________________________________________________

Purpose of Visit: Primary Facility:

Org/Agency/Co/Pgm Name: Abbreviation (if applicable):

Subcontracted to: Title or Position:

Last Name: First Name: Middle Name:

List all previous names:

Date of Birth: Social Security Number:

Passport #: Alien Registration #: Visa #:

Sex: Race: Height: Weight: Eye Color: Hair Color:

Current Address: City: State: Zip Code:

Prior Address: City: State: Zip Code:

Place of Birth: Email Address:

Home Phone: Alternate Phone (cell):

Current Driver's License Information

State: Operator:

ID Only license: OLN Number: Valid: Yes No

Previous Licenses (List all states & #’s that apply) State: Operator/Non-Operator #:

Professional/Medical Licenses: DEA Number: NPI Number:

In the block below, identify names, relationships, and locations of any inmates that you have visited or communicated with (email, mail, phone calls, monetary transaction, etc.) within the past 12 months. Attach additional sheets if necessary.

I confirm that all information contained on this clearance request has been verified by me to be complete and accurate. I also agree to abide by all Department rules and assume all risks which may result from the normal operation of a Department of Corrections facility.

Print Full Name: Date:

SECTION “B” (REQUESTING DOC STAFF MEMBER)

Print Staff Member Name: Employee #: Date:

Desc Event/Access: Period of Access Req:

*Attach additional pages if necessary to provide complete information.

1.1.4, Centralized Clearances Procedures Manual Section 4 – Centralized Clearance Check Procedures Issued: 4/20/2026 Effective: 4/27/2026 lauflores Highlight lauflores Highlight

Attachment 4-A

Consent to Release Information for Prison Rape Elimination Act Compliance

I, ______________________________, having applied to the Pennsylvania Department of Corrections (DOC) for a position (volunteer, contractor, agency temp, mentor, reentry service provider, contract service provider, official visitor, public visitor, intern, organizations and/or vendors, etc.) which includes access to DOC facilities, understand that the DOC must gather specific information about any prior employment to comply with the Prison Rape Elimination Act. I hereby authorize the DOC to investigate and ascertain any and all information concerning my prior employment as it relates to sexual abuse and sexual harassment. I understand that the information or documents may be obtained from any person, document or other source, inside or outside the Commonwealth of Pennsylvania. I hereby expressly authorize any former employer to release that information to the DOC.

I hereby release all persons and/or agencies from any liability which might otherwise result from the release of said information to any member of the DOC and/or their subcontractors.

In consideration of this release, the DOC and their subcontractors will regard all information obtained as confidential. I understand that the same will not be released to any individual, including myself, or organization, absent good cause.

I agree that the DOC may admit this information into evidence in order to defend any administrative or court proceeding. I retain the right to challenge the accuracy of such information, in such a proceeding, but waive all objections as to the admissibility of the information.

Have you ever been employed or volunteered in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution, (as defined in 42 U.S.C. 1997) to include state facilities for persons who are mentally ill, disabled, or intellectually disabled, or chronically ill or handicapped; residential care or treatment facilities for juveniles; and facilities that provide skilled nursing, intermediate or long-term care, or custodial or residential care? YES NO

If yes, this employment information must be provided as an attachment to this application.

Applicant Printed Name Date

______***DO NOT ACKNOWLEDGE BELOW IF YOU HAVE ACKNOWLEDGED ABOVE***_______

I, _________________________________, having made application for employment or access with the DOC, do not desire to authorize the release of information stated above. I understand that the DOC may not hire or allow access to a DOC facility to an individual who will come in contact with inmates without conducting a background investigation compliant with the Prison Rape Elimination Act, and that declining to agree to the above authorization will result in my being passed over for such employment or access.

Applicant Printed Name

1.1.4, Centralized Clearances Procedures Manual Section 4 – Centralized Clearance Check Procedures Issued: 4/20/2026 Effective: 4/27/2026

Date