Hr Child Procection

In: Other Topics

Submitted By sunneedee
Words 3693
Pages 15
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:____________________________________________________________________________________
Last First Middle

D.O.B. __________
Month

___________…...

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