Child Protection Forms Image Form – Fill Out and Use This PDF

GOVERNMENT OF THE DISTRICT OF COLUMBIA

Child and Family Services Agency

CFSA Contractor

__________________________

Agency Name

Request for a Child Protection Register Check (CPR Check)

This form may be used for either 1) an in-person request for a CPR Check (Part IV-A); 2) access to substantiated reports of child maltreatment to chief executive officers (CEO) or directors of day care centers, schools, or any public or private organization working directly with children, for the purposes of making employment decisions (Part IV-B); 3) or a child-placing agency licensed in D.C. for purposes of making placement decisions. (Part V).

INSTRUCTIONS: Please PRINT or TYPE, filling in all requested information, and sign in the places marked “Applicant Signature.” Please do not use initials to represent your first or middle name. However, if your first or middle name consists of only an initial, please indicate. A complete street address is required in addition to P.O. Box numbers.

All in person applicants are required to present one of the following valid photo identifications: Drivers License, State Identification Card, or Passport.

All requests for a CPR check in accordance with Part IV-B shall attach this form, with Part I, II, III and IV-B completed, along with a written request from the CEO or director which clearly articulates the basis for the request.

All requests for a CPR check in accordance with Part V shall attach this form, with Part I, II, III and IV-B completed. Note that if this request is accompanied by consent to release the information from the CPR as required in D.C. Code §4-1407.01(1)(A) then part IV-B of this form does not need to be filled out by the applicant.

PART I: Applicant Information

NAME:____________________________________________________________________________________

LastFirstMiddle

D.O.B. __________	___________	__________	Social Security No. ________--______--________
Month	Day	Year

List all names ever used (maiden, married, alias, etc.; continue on additional pages if needed):

_________________________________________________________________________________________

LastFirstMiddle

_________________________________________________________________________________________

LastFirstMiddle

_________________________________________________________________________________________

LastFirstMiddle

_________________________________________________________________________________________

LastFirstMiddle

_________________________________________________________________________________________

Last

First

Middle

Request for a Child Protection Register Check	Page 1 of 4
Revised – June 3, 2008

PART II: Applicant Residency List all complete addresses (exclude zip code) resided in for the past eighteen

(18)years and the dates lived there. Continue on additional pages if needed.

No. & Street (include apt. number if applicable)	City	State		Dates of Residency
No. & Street (include apt. number if applicable)	City	State		Dates of Residency
No. & Street (include apt. number if applicable)	City	State		Dates of Residency
No. & Street (include apt. number if applicable)	City	State		Dates of Residency
No. & Street (include apt. number if applicable)	City	State		Dates of Residency
No. & Street (include apt. number if applicable)	City	State		Dates of Residency

PART III: Household Information List all persons living at the current address. Print their Name, Date of Birth, and Relationship below.

NAME (Last, First. Middle)		D.O.B		RELATIONSHIP

PART IV: Applicant Release Use Part A for requests for an in-person CPR check. Use Part B for release of CPR check to a CEO or director of a day care center, school, or any public or private organization working directly with children, for purposes of making employment decisions. Use Part B for release of a CPR check for purposes of a child placement decision by a child-placing agency licensed in the District of Columbia.

A. For use only if requesting a CPR check in person:

I request access to the CPR for the limited purposes to determine if my name appears in it as being responsible for the abuse or neglect of a child. I have shown identification that is satisfactory to the CFSA CPR staff listed below.

___________________________________________	___________________
Applicant’s Signature	Date

Identification has been shown to me that I have deemed satisfactorily identifies the applicant:

Type of ID _________________________________	ID # _______________________
_________________________________________________
Signature

Name of CFSA employee (print): _____________________________________

Title: _____________________________________________

Request for a Child Protection Register Check	Page 2 of 4
Revised – June 3, 2008

B.For use only if consenting to a CPR check by either 1) a CEO or director of a day care center, school, or any public or private organization working directly with children for purposes of employment or 2) a child-placing agency licensed in the District of Columbia for purposes of placement of a child:

I consent that the information contained in the CPR (whether I am “in” or “not in”) may be released to my employer/potential employer or child-placing agency. A written request from the CEO or director is attached and it states the reasons for the request. Note that instead of the below consent, the child-placing agency may attach consent for release of information previously received in compliance with D.C. Code §4-1407.01.

___________________________________________

Name of Applicant

___________________________________________	___________________
Applicant’s Signature (must be signed in the presence of a Notary)	Date

DISTRICT OF COLUMBIA:

Subscribed and affirmed or sworn to me, in my presence,

on this __________day of ______________________, 20____.

Signature of Notary Public

______________________________

Notary Public, District of Columbia

My commission expires on ___/___/____.

Request for a Child Protection Register Check	Page 3 of 4
Revised – June 3, 2008

PART V: Agency Information (Please review entire application before forwarding to the CFSA CPR Office).

MAIL COMPLETED ORIGINAL FORM TO:

Child and Family Services Agency

4006th Street, SW Washington, DC 20024

Attn: Child Protection Register

TO BE COMPLETED BY REFERRING AGENCY REQUESTING RESPONSE VIA MAIL:

Agency Name:								Phone Number:
Email Address								Cubicle/Room # (CFSA
(optional):								Only)
Address:									City:
State:					Zip Code:		Attention:
									Last Name		First Name

TO BE COMPLETED BY REFERRING AGENCY REQUESTING RESPONSE VIA FAX:

Please fax the response to:

(Agency Name)

Attention:

(Designated Agent)

Fax Number

*********************************************************************************************************************************

I UNDERSTAND THAT I WILL NOT RECEIVE AN ORIGINAL COPY IN THE MAIL IF I REQUEST A FAXED COPY. ________

(Initials)

Request for a Child Protection Register Check	Page 4 of 4
Revised – June 3, 2008