| Check all that apply | Crime | Self | Other household member | Date of conviction, guilty plea, no contest plea or pending charges | Sentence |
|---|---|---|---|---|---|
□ | Manufacture, sale, delivery, holding, offering for sale or possession of any controlled substance or other drug or device | □ | □ |
| Check all that apply | Self | Household member | Child | |
□ | Involvement with a children and youth social service agency in Pennsylvania or a similar agency in another jurisdiction.What jurisdiction?: ____________ | □ | □ | □ |
□ | A determination or finding of abuse (i.e., indicated or founded report) by a children and youth social service agency or court in Pennsylvania or a similar agency or court in another jurisdiction.What jurisdiction?: ____________ | □ | □ | □ |
□ | An adjudication of dependency involving this child or any other child under Pennsylvania's Juvenile Act, or a similar law in another jurisdiction.What jurisdiction?: ____________Is the case active?: ____________ | □ | □ | □ |
□ | A history of perpetrating “abuse” as that term is defined in the Protection from Abuse Act, 23 Pa.C.S. § 6102. | □ | □ | □ |
□ | A history of perpetrating “sexual violence” or “intimidation” as those terms are defined in 42 Pa.C.S. § 62A03 (relating to protection of victims of sexual violence and intimidation). | □ | □ | □ |