Students who volunteer in the LCHFC will be providing service to and interacting with the community. Therefore, they are required to attend an informational meeting and submit required clearances.
It is our intention to provide compassionate and high quality care to those we serve, and to maintain a safe and healthy environment for those who provide service. With that in mind, the following is required for all students to volunteer in the LCHFC:
- Review the CFPB Summary of Rights document. Sign the Acknowledgement and Authorization for Background Checks. Provide to the Leahy Community Health and Family Center. You must understand your rights prior to submitting for Federal and State Clearances.
A Pennsylvania State Police Criminal Background Check (every 5 years)
Pennsylvania Child Abuse Clearance (every 5 years)
For out-of-state residents and international students: an FBI Criminal Background Check
Proof of completed immunizations, including an annual flu vaccine, and evidence of a tuberculin skin test (PPD or Mantoux) within the past year.
- Acknowledgement of Confidentiality in accordance with the Health Insurance Portability Accountability Act (HIPAA)
Documentation is the responsibility of the student and must be submitted in advance of volunteering.
NOTE: If you are doing a clinical rotation, internship, or residency, submit all paperwork to the academic department.
All other student volunteers should submit paperwork to the LCHFC.
Pennsylvania State Police Criminal Background Check
Form: Pennsylvania State Police: Request for Criminal Record Check Form (SP4-164) or Click Here to apply online.
Child Abuse Clearance
This form can be completed in print and mailed in, or the form can be completed online for fast results.
To complete this clearance online, click here. You will be prompted to create an individual account by entering a login and retrieving a pre-determined password from your email. You will be given the option to customize your password and log into your account. When completing this form online, check the "Volunteer" box to waive the fee.
Another option is to print the form and mail it in:
CY113 form – English Child Abuse Clearance. *Under "PURPOSE OF CLEARANCE" please check "School Employee"
CY113 form - Spanish Child Abuse Clearance. *Bajo "MOTIVO DEL CERTIFICADO" por favor marque "Empleado de escuela"
FBI Background Check
Follow the instructions on completing an FBI background check and finger printing. To begin the registration process, click here and use this code 1KG6ZJ.
HIPAA Acknowledgment of Confidentiality
Students must sign and submit the following Acknowledgment of Confidentiality form in accordance with the Health Insurance Portability Accountability Act (HIPPA). Also review the following video to ensure you understand your legal and ethical obligation when working with Leahy Clinic patients.