BACKGROUND CLEARANCE INSTRUCTIONS STUDENT …

BACKGROUND CLEARANCE INSTRUCTIONS ? STUDENT APPLICANT

The amended Child Protective Services Law, effective December 31, 2014, and accompanying policies; PASSHE Board of Governors 2014-01-A (Protection of Minors) and Bloomsburg University's PRP 2410 (Background Screening, Protection of Minors and Volunteerism) requires all university employees to successfully complete background clearances every three (3) years. Specifically, all employees are required to successfully complete the Pennsylvania Child Abuse History Clearance, Pennsylvania State Police Criminal Record Check, and FBI Federal Criminal History Record. Please complete the actions listed below in order to comply.

1. Complete the form entitled "BLOOMSBURG UNIVERSITY OF PENNSYLVANIA APPLICANT ACKNOWLEDGMENT AND CONSENT FOR CRIMINAL BACKGROUND CHECK".

2. Go to to obtain your one time use payment code for completing the Pennsylvania Child Abuse History Clearance. You must use your Husky ID and password. Copy or print the code to proceed with the next step.

3. Go to to complete your Pennsylvania Child Abuse Clearance electronically utilizing the payment code obtained in the previous step. a. Select "CREATE A NEW ACCOUNT" to create a Keystone ID, which is a username. Please retain this information for future access. b. If you have previously created a Keystone ID, "LOGIN" with your Keystone ID and password. Additional Instructions for registering and completing the online form are available under "USERS GUIDES CWIS CITIZENS ACCOUNT" at: .

Completion of this step will take approximately thirty (30) minutes. You will receive an original report, for your records, via email. Forward a copy of the registration confirmation to Ellen Sudbury (esudbury@bloomu.edu), Compliance Coordinator, Rm 104B, Waller Administration Building.

4. Apply for the FBI Federal Criminal History Record at: . This link will direct you to registration for the Department of Human Services (formerly DPW). a. Select "Register Online". b. Go to "Payment Type" and Select "AGENCY". c. Go to "Agency ID" and enter ABID #: PALS20954 d. Go to "Billing Password" and enter ABID Password: P151652910 (BU employees only) e. Select "EMPLOYMENT WITH SIGNIFICANT LIKELIHOOD OF REGULAR CONTACT WITH CHILDREN" as "Reason Fingerprinted". f. Make two (2) copies of the registration. i. Present one copy at the FBI fingerprint site. ii. Forward one copy to Ellen Sudbury (esudbury@bloomu.edu), Compliance Coordinator.

5. Present your registration confirmation and photo ID at a Cogent FBI fingerprint site. The Bloomsburg University Store is an authorized fingerprint collection location. The store may be contacted at (570) 389-4175 for inquiries. Other authorized locations are listed on the registration website.

6. Return the following documents to, Ellen Sudbury (esudbury@bloomu.edu), Compliance Coordinator, Waller Administration Building, Room 104B. (570-389-2725) a. BLOOMSBURG UNIVERSITY OF PENNSYLVANIA APPLICANT ACKNOWLEDGMENT AND CONSENT FOR CRIMINAL BACKGROUND CHECK. Return this document immediately upon completion. b. Forwarded email of Pennsylvania Child Abuse History confirmation. Return this document immediately upon completion. c. Forwarded copy of FBI fingerprint confirmation. Return this document immediately upon completion. d. Original Results of FBI Fingerprint background clearance once received at your registration address. The current lead time for receipt of this document is ten (10) to fourteen (14) days.

BLOOMSBURG UNIVERSITY OF PENNSYLVANIA APPLICANT ACKNOWLEDGEMENT AND CONSENT FOR CRIMINAL BACKGROUND CHECK

1. _______________________________________ hereby acknowledge and consent to the following: (PRINT NAME)

2. I have applied for a position with Bloomsburg University and have been advised that all university employees are required to satisfy the requirements of the Pennsylvania Child Protective Services Law (CPSL).

3. I acknowledge that CPSL requires a Pennsylvania State Police Criminal History Report, Pennsylvania Department of Human Services Child Abuse History Clearance and a Federal Bureau of Investigation Criminal History Report.

4. I further acknowledge that I will provide the original Federal Bureau of Investigation Criminal History Report (fingerprint report) to Human Resources at Bloomsburg University.

5. I will use the provided payment code to submit my Pennsylvania Department of Human Services Child Abuse History Clearance report electronically, which will allow Bloomsburg University access to the final report.

6. I understand that Human Resources at Bloomsburg University will run the Pennsylvania State Police Criminal History report (e-PATCH) on my behalf and I am providing the following information for them to do so.

Full Name (print)

_________________________________________________________________

Date of Birth

_________________________________________________________________

Full Social Security Number _________________________________________________________________

Aliases and/or Maiden Name _________________________________________________________________

Race

_________________________________________________________________

Race is a required field in the Pennsylvania State Police application for the Criminal History Report. Failure to provide race on

this form will result in race being reported as unknown to the Pennsylvania State Police.

7. I understand that CPSL permits (but does not require) Bloomsburg University to hire me on a provisional basis for an approved time period not to exceed ninety (90) days.

8. I understand that during any authorized period of provisional employment/participation, I will not be permitted to work alone with children and must work in the immediate vicinity of a permanent Bloomsburg University employee.

9. I understand that Bloomsburg University may immediately terminate my provisional employment/participation should the Pennsylvania State Police, Pennsylvania Department of Human Services and/or the Federal Bureau of Investigation be unable to provide the required reports within the approved provisional period.

_____________________________________________ SIGNATURE

_________________________________________ DATE

_____________________________________________ E-MAIL ADDRESS

__________________________________________ TELEPHONE NUMBER APPLICANT FOR:

FACULTY STAFF STUDENT EMPLOYMENT VOLUNTEER

DEPARTMENT: ________________

Approved by University Legal Counsel April 13, 2015

ADDITIONAL INFORMATION/SUGGESTIONS FOR COMPLETING THE BACKGROUND CLEARANCES

1. COMPLETING THE BLOOMSBURG UNIVERSITY OF PENNSYLVANIA APPLICANT ACKNOWLEDGEMENT AND CONSENT FOR CRIMINAL BACKGROUND CHECK FORM a. Write legibly (we need to be able to read your SS# and DOB to enter them correctly for your PA State Police clearance. b. Race does not need to be filled in. If it is left blank, we will enter "unknown" in the required field for the PA State Police background clearance. c. Be sure to fill in your department and all contact information

2. OBTAINING YOUR PAYMENT CODE a. When obtaining your payment code from the BloomU portal, please copy and paste it to avoid confusing the O and 0 or the I and 1. b. If you forget or lose your code, log back in and the site will give you the same code again. The code is linked to your BU login.

3. COMPLETING THE CHILD ABUSE HISTORY CLEARANCE a. Use Internet Explorer b. Your Keystone ID is another name for your login (that you create). Do not use your BU login or the payment code in this field. c. Write down your Keystone ID, password and the answers to your security questions so you can log in to retrieve your results d. If you have already created an account in the past, you will need to log in using those credentials. If you can't remember them, contact the CWIS support center. e. When prompted, enter your Social Security number. Your clearance will clear much quicker (sometimes immediately). Without your Social Security number your clearance will take days longer to process. f. Use your home address (not your BU address) on your clearance. g. Use "School Employee NOT governed by the Public School code" as your Application Purpose.

4. FBI FEDERAL CRIMINAL HISTORY CLEARANCE a. Register under the Department of Public Welfare/Human Services not with the Department of Education. b. Use the address where you will be living in 2 weeks as your mailing address. The original report will be mailed to that address and you must bring the original report in to HR before you are approved to work. c. If you make a mistake on your registration, you can cancel it and re-register. Don't continue with your fingerprinting if you spelled your name wrong or typed in the wrong SS#. We will require you to have the clearance repeated. d. Use lotion on your hands prior to going to have your prints taken. It reduces the risk of having your prints rejected. e. The results will be mailed to you in a white business envelope from the Commonwealth of Pennsylvania, Department of Public Welfare, on blue marbled paper.

Supervisor's Responsibility:

STUDENT EMPLOYMENT CHECKLIST

For already enrolled students: Please check the Active Student List on the "S" Drive: under BU documents, under Payroll/Active Student List and write the PERSONNEL # of the student on the placement card. If you do not find the Personnel #, then attach the completed forms listed below (Checklist for New Students). All forms are available on the "S" Drive: under the folders BU documents/ Payroll; also at . (Please save this link as a favorite).

Please return this checklist along with all completed forms to Student Payroll, WAB-121. Ensure that both you and the student sign all applicable paperwork. PACKETS MISSING ANY OF THE FIRST FIVE (5) FORMS WILL BE RETURNED TO THE APPROPRIATE STUDENT SUPERVISOR.

Please do not hesitate to contact Nikki Black, Student Payroll Coordinator, with questions. Thank

you!

Checklist for New Student Employee paperwork to be completed for Payroll processing

- Placement Card

- I-9 Form- Signed and dated by both student and supervisor. A student is not LEGALLY eligible to begin employment until they have provided the ORIGINAL DOCUMENTS required to complete the I-9 and they have signed and dated the I-9. This should be done by the first day of employment. The supervisor has until the third day of employment to complete the form. Regardless of the documents used to complete the I-9, you must include a copy of the student's social security card.

- Local Earned Income Tax Residency Certification Form

- W4 Form

- Direct Deposit Form

Student Voluntary Self-Identification Survey Form. Declaration is voluntary; however, the form must be signed and dated.

Local Service Tax Form Please complete this form only if:

You expect to make less than $12,000 annually, or You work multiple jobs and have this tax deducted from another employer (Please provide a copy of proof of the LST payment from your other employer).

Background check & clearance forms complete. Please refer to checklist.

Student Supervisor (please print)

Student Payroll Checklist

Date

Revised 1/2017

DCED-CLGS-06 (1-11)

COMMONWEALTHOFPENNSYLVANIA DEPARTMENTOFCOMMUNITY&ECONOMICDEVELOPMENT GOVERNOR'S CENTER FOR LOCAL GOVERMENT SERVICES

LOCALEARNEDINCOMETAX RESIDENCY CERTIFICATIONFORM

T O E M P L O Y E R S / TA X PAY E R S : This form is to be used by employers and/or taxpayers to report essential information for the collection and distribution of Local Earned Income Taxes. This form must be utilized by employers when a new employee is hired or when a current employee notifies employer of a name and/or address change.

NAME (Last, FIrst, Middle Initial)

EMPLOYEEINFORMATION - RESIDENCELOCATION

FIRST LINE OF ADDRESS (If POBox, please include actual street address)

Personnel Number

SECOND LINE OF ADDRESS CITY MUNICIPALITY (City, Borough, Township)&LUFOH2QH

STATE

ZIP CODE

Personnel # or last 4 digits of SS#

DAYTIME PHONE NUMBER

COUNTY

PSDCODE3D\UROO8VH2QO\

TOTAL RESIDENT EIT RATE

EMPLOYERINFORMATION - EMPLOYMENTLOCATION

EMPLOYER NAME (Use Federal ID Name)

Bloomsburg University of Pennsylvania

EMPLOYER FEIN

25-1690694

FIRST LINE OF ADDRESS (IIf POBox, please include actual street address)

400 East Second Street

SECOND LINE OF ADDRESS

CITY

Bloomsburg

MUNICIPALITY (City, Borough, Township)

Bloomsburg

COUNTY

Columbia

STATE

PA

ZIP CODE

17815

PHONE NUMBER

570-389-4415

PSDCODE

1 9 030 2

MUNICIPALNON-RESIDENT EITRATE

1.0%

SIGNATURE OF EMPLOYEE PHONE NUMBER

CERTIFICATION

EMAIL ADDRESS

DATE

For information on obtaining the appropriate MUNICIPALITY (City, Borough, Township), PSD CODES and EIT (Earned Income Tax) RATES, please refer to the Pennsylvania Department of Community & Economic Development website:



Select Get Local Gov Support, >Municipal Statistics

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