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Checklist of Requirements

 

Clarion University College of Education and Human Services
Office of Field Services, 102 Stevens Hall

CSD Field Experience Requirement List

All CSD majors must supply to the Office of Field Services (OFS) the following information.  Some require forms to be completed and submitted to the appropriate Offices prior to coming to the OFS.  If a specific form is needed, this symbol, §, is next to the requirement.  These forms are available on the OFS Website.

Requirements - Please check them off when completed and submitted to the OFS:

_____  FBI Clearance.  Follow the directions in the OFS Clearance Web section and complete this application online.

 _____  § Act 33 Child Abuse Clearance.  This form must be mailed in with payment.  For faster return, submit it through the local state representative's office on second Avenue in Clarion.  You should receive it within 3 weeks.

 _____  Act 34 Criminal Record Clearance.  Follow the directions in the OFS Clearance Web section and complete this application online.

_____ § Act 24 Clearance Information.  Act 24 adds several new crimes to the previous list of offenses which disqualify individuals from school employment. The Pennsylvania Department of Education (PDE) developed Form PDE-6004 for reporting purposes.  Please complete and submit a signed Form PDE-6004 to the Office of Field Services. Web

 _____  §  Mantoux (TB) Test: valid for 2 years from date of inoculation. This will be required every two years during your undergraduate career here.  OFS Website has the form.  This MUST be completed at Keeling Health Center.  Watch for their special testing schedule each semester College of E&HS majors.

_____   § Physical Examination valid for 1 year from date of issuance.  OFS Website has this form. This will be required every year during your undergraduate career here.  This MUST be completed at Keeling Health Center.  Watch for their special testing schedule each semester College of E&HS majors. You will make the appointment during their special testing schedule each semester.

_____  § Required Immunizations: Tetanus, Polio Vaccine, MMR: Measles - Mumps - Rubella/Rubeolla, Hepatitis B.  This is part of the physical form and can be found at your primary care physician's office or in your home medical records.  If you did not have these immunizations, you must get them.  Keeling Health Center personnel can help you with this.

_____  § Confidentiality Disclaimer.  OFS Website has this form.

_____  Liability Insurance: Minimum of $1,000,000 per claim. Check the OFS Website for on-line providers.

_____  Health Insurance: Is not yet required but preferred.  If insurance is needed, contact the Keeling Health Center.  If you have this, please present proof, i.e. insurance card, to the OFS.  A copy will be made and placed in your file.

_____ Please sign and return one copy of this requirements list to the OFS.  Please keep the second copy on file in your own professional materials file for future reference.

 

I understand the above listed requirements for all field experiences.  I know that it is my responsibility to provide this information to the OFS.  I also know that I will not be permitted to begin any field experience without this submitted information.

Name (print): ___________________________________________ Student ID# ______________

Student Signature: ____________________________________________ Date: ______________