BACKGROUND CLEARANCE INSTRUCTIONS STUDENT APPLICANT

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1 BACKGROUND CLEARANCE INSTRUCTIONS STUDENT APPLICANT The amended Child Protective Services Law, effective December 31, 2014, and accompanying policies; PASSHE Board of Governors 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 . 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: P (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) 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. ( ) a. BLOOMSBURG UNIVERSITY OF PENNSYLVANIA APPLICANT ACKNOWLEDGMENT AND CONSENT FOR CRIMINAL BACKGROUND CHECK. Return this document immediately upon completion. b. Forwarded 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.

2 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 ADDRESS TELEPHONE NUMBER APPLICANT FOR: FACULTY STAFF STUDENT EMPLOYMENT VOLUNTEER DEPARTMENT: Approved by University Legal Counsel April 13, 2015

3 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.

4 STUDENT EMPLOYMENT CHECKLIST Supervisor s Responsibility: 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) Date Student Payroll Checklist Revised 1/2017

8 DCED-CLGS-06 (1-11) LOCAL EARNED INCOME TAX RESIDENCY CERTIFICATION FORM COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF COMMUNITY & ECONOMIC DEVELOPMENT GOVERNOR S CENTER FOR LOCAL GOVERMENT SERVICES TO EMPLOYERS/TAXPAYERS: 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) EMPLOYEE INFORMATION - RESIDENCE LOCATION FIRST LINE OF ADDRESS (If PO Box, please include actual street address) SECOND LINE OF ADDRESS CITY STATE ZIP CODE DAYTIME PHONE NUMBER MUNICIPALITY (City, Borough, Township) COUNTY PSD CODE TOTAL RESIDENT EIT RATE EMPLOYER NAME (Use Federal ID Name) EMPLOYER INFORMATION - EMPLOYMENT LOCATION EMPLOYER FEIN FIRST LINE OF ADDRESS ( I If PO Box, please include actual street address) SECOND LINE OF ADDRESS CITY STATE ZIP CODE PHONE NUMBER MUNICIPALITY (City, Borough, Township) COUNTY PSD CODE MUNICIPAL NON-RESIDENT EIT RATE SIGNATURE OF EMPLOYEE CERTIFICATION DATE PHONE NUMBER ADDRESS 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

11 Return to: Student Payroll Waller Administration Bldg. STATE SYSTEM of HIGHER EDUCATION DIRECT DEPOSIT AUTHORIZATION Name Social Security OR Personnel Number address (Please Print) I hereby authorize the Pennsylvania State System of Higher Education to (check one) I hereby decline direct deposit (Complete section 2 below) START STOP CHANGE Total bi weekly payroll deduction to the Financial Institution shown below. You may designate any bank, savings and loan association, or credit union in the U.S. that (1) is a member of the Federal Reserve System and (2) accepts electronic funds transfer. Payroll will notify you if the institution you choose does not qualify. Financial Institution s Name Transit Routing Number Account Number Type of Account (Checking or Savings) Deduction Amount (Dollar Amount or Net) Effective with pay date of I have an established account at the Financial Institution indicated above, and authorize the State System of Higher Education to initiate credit entries and to initiate debit entries and adjustments for any credit entries in error to my (our) account (s) indicated above. I have provided a copy of a voided check or a deposit slip (see attached) solely for the purpose of verifying my account number and the Financial Institution s routing number. My authorization will remain in effect until revoked by me in writing or I terminate my employment with the State System of Higher Education. Signature Date Section 2-Declining Direct Deposit- By declining direct deposit of my pay, I will be required to pick up my paycheck in the Student Payroll Office, 2 nd Floor, Waller Administration Bldg, each biweekly payday between 9:00am to 11:30am. If I have not picked up my check by 11:30am, the check will be mailed to the address stated on my check. CHECKS CAN ONLY BE DISTRIBUTED ON PAY DAY Signature Date

12 Voluntary Self-Identification Survey In order for Bloomsburg University to comply with Equal Employment Opportunity laws and regulations and to assess our recruitment and retention efforts, we solicit the ethnicity and gender of all employees. Our affirmative action/social equity efforts would be greatly enhanced by providing this information. We would appreciate your completion of this form. Please return to Student Payroll, Waller Administration Building. Please be advised that this request is optional. Refusal to provide this information will not subject you to discharge or any adverse treatment. Any information obtained will only be used in compliance with the foregoing statutes and regulations issued thereunder. Also, information obtained concerning individuals shall be kept confidential, except that (1) supervisors and managers may be informed regarding restrictions on the work or duties of individuals with disabilities and disabled veterans, regarding necessary accommodations; (2) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition may require emergency treatment; and (3) government officials investigating compliance with the above laws may be informed. Last Name: First Name: Address: Gender: (Circle one) Male Female 1) What is your ethnicity (Do you consider yourself to be Hispanic/Latino/Spanish)? Hispanic or Latino: Persons of Cuban, Mexican, Puerto Rican, South or Central America or other Spanish culture or origin, regardless of race. Not Hispanic or Latino 2) What is your race (In addition, select one or more of the following racial categories to describe yourself)? Hispanic of any race For non-hispanics only: American Indian or Alaskan Native: Persons having origins in any of the original peoples of North America, and who maintain cultural identification through tribal affiliation or community recognition. Asian: Persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia. Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: Persons having origins in any of the black racial groups of Africa. Native Hawaiian or Pacific Islander: Persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White/Caucasian (Not of Hispanic origin): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East. Two or more races Race and/or ethnicity unknown Non-resident alien How do you classify yourself? (if applicable)

13 Special Disabled Veteran: means (1) a veteran who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Department of Veterans Affairs for a disability (a) rated at 30 percent or more, or (b) rated at 10 or 20 percent in the case of a veteran who has been determined under Section 1506 of Title 38, USC to have a serious employment handicap or (2) a person who was discharged or released from active duty because of a service-connected disability. Veteran of the Vietnam-Era: means a person who: (1) served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred: (a) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (b) between August 5, 1964 and May 7, 1965, in all other cases; (2) was discharged or released from active duty for a service-connected disability if any part of such active duty was performed (a) in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or (b) between August 5, 1964 and May 7, 1965, in all other cases. Other Veteran: means a veteran who served on active duty during a way or in a campaign or expedition for which a campaign badge has been authorized. To identify the campaigns or expeditions that meet this criterion, contact the Office of Personnel Management (OPM) and ask for the OPM VETS Guide, Appendix B. A local OPM telephone number may be found in the telephone book under nearest OPM location. For those with Internet access, the information required to make this determination is available at Individual with a disability: means a person who: has a physical or mental impairment that substantially limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairment. Do you have a mobility concern that would prevent you from evacuating a building in an emergency? (Circle one) Yes No If you have been self-identified as an individual with a disability or as a special disabled veteran, please describe your disability: Have accommodations for your disability been made to aid you in performing your job?: (Circle one) Yes No If yes, please describe such accommodations: If you feel that accommodations for your disability would aid you in performing your job, please describe: Signature Date Bloomsburg University of Pennsylvania is committed to affirmative action by way of providing equal educational and employment opportunities for all persons without regard to race, religion, age, gender, ancestry, lifestyle, or disability.

14 LOCAL SERVICES TAX EXEMPTION CERTIFICATE Tax Year APPLICATION FOR EXEMPTION FROM LOCAL SERVICES TAX A copy of this application for exemption from the Local Services Tax (LST), and all necessary supporting documents, must be completed and presented to your employer AND to the political subdivision levying the Local Services Tax where you are principally employed. This application for exemption from the Local Services Tax must be signed and dated. No exemption will be approved until proper documentation has been received. Name: Address: City/State: Soc Sec #: Phone #: Zip: REASON FOR EXEMPTION 1. MULTIPLE EMPLOYERS: Attach a copy of a current pay statement from your principal employer that shows the name of the employer, the length of the payroll period and the amount of Local Services Tax withheld. List all employers on the reverse side of this form. You must notify your other employers of a change in principal place of employment within two weeks of the change. 2. EXPECTED TOTAL EARNED INCOME AND NET PROFITS FROM ALL SOURCES WITHIN (municipality or school district) WILL BE LESS THAN $ : Attach copies of your last pay statements or your W-2 for the year prior. If you are self-employed, please attach a copy of your PA Schedule C, F, or RK-1 for the prior year. 3. ACTIVE DUTY MILITARY EXEMPTION: Please attach a copy of your orders directing you to active duty status. Annual training is not eligible for exemption. You are required to advise the tax office when you are discharged from active duty status. 4. MILITARY DISABILITY EXEMPTION: Please attach copy of your discharge orders and a statement from the United States Veterans Administrator documenting your disability. Only 100% permanent disabilities are recognized for this exemption. EMPLOYER: Once you receive this Exemption Certificate, you shall not withhold the Local Services Tax for the portion of the calendar year for which this certificate applies, unless you are otherwise notified or instructed by the tax collector to withhold the tax. Tax Office: Address: City/State: Phone #: Zip: IMPORTANT NOTE TO EMPLOYERS 1. The municipality is required by law to exempt from the LST employees whose earned income from all sources (employers and self-employment) in their municipality is less than $12,000 when the levied rate exceeds $ The school district for the municipality in which your worksite(s) is located may or may not levy an LST. If it does, the income exemption provided may differ from the municipality and can be anywhere from $0 to $11, Contact the tax office where your business worksites are located to obtain this information. LST Exemption 10-07

15 Employment Information: List all places of employment for the applicable tax year. Please list your PRIMARY EMPLOYER under #1 below and your secondary employers under the other columns. If self employed, write SELF under Employer Name column. Employer Name Address Address 2 City, State Zip Municipality Phone Start Date End Date Status (FT or PT) Gross Earnings 1. PRIMARY EMPLOYER Employer Name Address Address 2 City, State Zip Municipality Phone Start Date End Date Status (FT or PT) Gross Earnings PLEASE NOTE: All information received by the Tax Collector is considered to be CONFIDENTIAL and is only used for official purposes relating to the collection, administration and enforcement of the LOCAL SERVICES TAX. I DECLARE UNDER PENALTY OF LAW THAT THE INFORMATION STATED ON AND ATTACHED TO THIS FORM IS TRUE AND CORRECT: SIGNATURE: DATE: LST Exemption 10-07

16 Student Name: Student ID#: State of Understanding of Privacy Act Provisions I understand that by virtue of my employment with the Bloomsburg University Office I may have access to records which contain individually identifiable information, the disclosure of which is prohibited by the Privacy Act of I understand that I should only view information in any form paper, electronic or otherwise that is necessary for the performance of my job responsibilities. I understand that I should only access this information on computer systems during the times which I am working. I acknowledge that I fully understand that the willful or intentional disclosure by me of this information to any unauthorized person, could subject me to criminal and civil penalties imposed by the law. I further acknowledge that such willful or intentional unauthorized disclosure also violates the school s policy and could constitute just cause for disciplinary action including termination of my employment regardless of whether criminal or civil penalties are imposed. Student Signature Date Witness Date Department

Last Name First Name Middle Initial ADDRESS Street City County State Zip

Last Name First Name Middle Initial ADDRESS Street City County State Zip APPLICATION FOR EMPLOYMENT Kolberg-Pioneer, Inc. An Equal Opportunity Employer (HRF-002-03 01/16) This application is valid for the calendar year of 2018. Kolberg-Pioneer, Inc. will provide the Social