Security Clearance Form.pdf
PDF 194 KB Posted
- Solicitation number
- DGS C-1576-0011 Phase 1
- Issued by
- Somerset County, Pennsylvania
About this file
This document is a Centralized Clearance Check Information Request form issued by a Department of Corrections (DOC) on 11/2/2020, effective 11/9/2020. The form is designed to collect comprehensive personal and professional information from individuals seeking access to DOC facilities, including candidates from various categories such as agency temporary services, contract service providers, interns/externs, volunteers, vendors, and official or public visitors. The form requires detailed personal information including previous work history, potential prior involvement in correctional facilities, personal identifiers, contact details, and an acknowledgment of Department rules and risk assumption.
The clearance request form is a confidential screening tool that requires complete and accurate information, with warnings that falsification or omission of pertinent details could result in disapproval or potential criminal prosecution. The form covers multiple verification aspects including previous institutional work experience, sexual misconduct history, personal identification details, driver's license information, professional licenses, and a requirement to disclose any relatives or close friends currently in DOC facilities. The document emphasizes the responsibility of the requestor to initiate clearance renewals and provides sections for both the candidate (Section A) and the requesting DOC staff member (Section B) to complete the clearance process.
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Text version
CENTRALIZED CLEARANCE CHECK INFORMATION REQUEST
1.1.4, Centralized Clearances Procedures Manual Attachment 4-A Section 4 – Centralized Clearance Check Procedures Issued: 11/2/2020 Effective: 11/9/2020
Please type the following information. Enter N/A in any space that does not apply. All information will be maintained confidentially, but must be provided in order to complete a clearance check. Falsification or omission of pertinent information will be considered as justification for 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” (CANDIDATE)
Have you ever worked in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution? ☐ Yes ☐ No Have you ever been 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 ☐ Official Visitor (please select one):
☐ Government ☐ PA Prison Society ☐ Public Visitor (please select one):
☐ Ministry ☐ Criminal Justice Agency ☐ Entertainment, Sports, Activities, Guest Speaker ☐ Other (please explain):
Purpose of Visit: Primary Facility:
Organization/Agency/Company/Program 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:
Identify names, relationships, and locations of any relatives or close friends in any DOC facility:
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 facility.
Signature: Date:
SECTION “B” (REQUESTING DOC STAFF MEMBER)
Requesting Staff Member: Employee #: Date of Request:
Describe Specific Event or Access: Specific Period of Access Required:
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