CPR_Check_Attachments.pdf

GOVERNMENT OF THE DISTRICT OF COLUMBIA

Child and Family Services Agency

*** 0 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. 0. 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-8 shall attach this form, with Part I, II, Ill and IV-8 completed, along with a written request from the CEO or director which clearly articulates the basis for the request.

I

All requests for a CPR check in accordance with Part V shall attach this form, with Part I, II, Ill and IV-8 completed. Note that if this request is accompanied by consent to reiease the information from the CPR as required in D. C. Code §4-1407. 01 (1 )(A) then part IV-8 of this form does not need to be filled out by the applicant.

PART I: A licant Information

Last First Middle

D.0 .8. ___ _ Social Security No. __________ _ Month Day Year

Race: ----------------- Gender: D Male D Female

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

Last

Last

Last

Last

Last

Request for a Child Protection Register Check Revised - April 30, 2008

First Middle

First Middle

First Middle

First Middle

First Middle

PART II: Applicant Residency List all complete addresses (exclude zip code) resided in for the past eighteen (1 B) yea1 s 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 Ill: Household Information List all persons living at the current address. Print their Name, Date of Birth, and Relationship below.

NAME (Last, First. Middle) D.0.8 RELATIONSHIP

PART IV: Applica_nt 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): ----------------

Request for a Child Protection Register Check Revised - April 30, 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. Cod.e §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

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

MAIL COMPLETED ORIGINAL FORM TO:

Child and Family Services Agency 200 I Street, SE

Washington, DC 20003 Attn: Child Protection Register

);>- TO BE COMPLETED BY REFERRING AGENCY REQUESTING RESPONSE VIA MAIL:

Agency Name:

Email Address (optional):

Address:

State:

Phone Number:

Cubicle/Room # (CFSA Only)

City:

Zip Code: Attention: ------ Last Name

);>- TO BE COMPLETED BY REFERRING AGENCY REQUESTING RESPONSE VIA FAX:

Please fax the response to:

Attention:

Fax Number

District of Columbia Courts

(Agency Name) Dianne King, Attorney Advisor

(Designated Agent)

(202) 879-7566

First Name

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

FAXED COPY. DK

(Initials)

Request for a Child Protection Register Check

Virginia Department of Social Services/Child Protective Services Central Registry Release of Information Form

Part I: INSTRUCTIONS,.._-- R'°"'e-ad all i·nstructions before completing form: Incomplete for_m_s....:wi'"",.._·1-1 b- e- re-tu- rned.

1. Type or print legibly in ink. Indicate NIA if a question is not applicable 2 . Submit a separate form for each individual whose name is to be searched. MUST USE THIS FORM BEGINNING 11/01/09

3. Provide proof of identity and sign Part Ill in the presence of a Notary Public.

4. Enclose a $7.00 money order, company /business check or cashiers check payable to: Virginia Department o f Social Services

(unless waived) DO NOT SEND CASH or PERSONAL CHECKS. This fee is nonrefundable. $25 will be charged for checks returned for insufficient funds.

5. Search results disseminated beyond the requesting agency/individual named below are not considered official.

6 . Mail completed form to: VA Dept. of Social Services, 801 East Main St , 6th f loor, OBI Search Unit, Richmond VA 23219-2901 MAIL SEARCH RESULTS TO A I d" "d I A th . d A t R f S h ,gency, n IVI ua or u orize gen eques mg earc

Name Dist ric t of Columbia Courts Payment Code/ Fips Code (If assigned by Central Registry Unit)

Address: 616 H Street NW, - Suite 616

City Washington State DC Zip Code 20001 Contact Person Contact's Phone Number Mandatory for all coded agencies

Dianne King, Attorney Advisor (202) 879-4261

Purpose of Search, Check one: D Adam Walsh Law D Adoptive Parent D Babysitter/Family Day Care D CASA D Children's Residential Facility D Custody Evaluation 0 Day Care Center D Foster Parent D Institutional Employee [] Other Employment .D School Personnel D Volunteer D Other j Part II: TO BE COMPLETED IN FULL1 ~y INDIVIDUAL WHOSE NAME IS BEING SEARCHED Identifying Information for Person Being Searched.: , · Last Name First Name Full Middle Name - no initials (if name is initial only state Initial Only)

Maiden Name Sex I Race I Date of Birth Social Security Number 0Male D Female MM/DD/YY

Driver's License Number Other names Used by the Individual (Nicknames, previous married names, etc.)

Current Address Street Current Address City Current Address State I Current Address Zip Code

Prior Address Street Prior Address City Prior Address State Prior Address Zip Code Date of Residency

Prior Address Street Prior Address City Prior Address State Prior Address Zip Code Date of Residency

Prior Address Street Prior Address City Prior Address State Prior Address Zip Code Date of Residency

CURRENT SPOUSE INFORMATION I 0 CHECK HERE IF NOT CURRENTLY MARRIED .

Last Name First Name Full Middle Name I Maiden Name Sex I Race

Birth Date 0Male D Female MM/DD/YY

ALL PREVIOUS SPOUSES 0 CHECK HERE IF NOT PREVIOUSLY MARRIED

Last Name First Name Full Middle Name Maiden Name Sex Race Birth Date

0Male

I

D Female MM/DD/YY Last Name First Name Full Middle Name Maiden Name Sex Race Birth Date

0Male D Female MM/DD/YY l Full Names of All Child ren: ,(ln_clude Adult Children, Step, Foster, Children Not Living with you. Attach additional 12a12er if needed) .I D Check here if you do not have children Last Name First Name Full Middle Name Sex Race Birth Date

0Male D Female MM/DD/YY

Last Name First Name Full Middle Name Sex Race Birth Date 0Male D Female MM/DD/YY

Last Name First Name Full Middle Name Sex Race Birth Date 0Male 0 Female MM/DD/YY

Last Name First Name Full Middle Name . Sex Race Birth Date 0Male D Female MM/DD/YY

Last Name First Name Full Middle Name Sex Race Birth Date 0Male 0 Female MM/DD/YY

Virginia Department of Social Services/Child Protective Services Central Registry Release of Information Form

Part Ill: CERTIFICATION AND CONSENT FOR RELEASE OF INFORMATION I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge. Pursuant to Section 2.2-3806 of the Code of Virginia, I authorize the release of personal information regarding me which as been maintained by either the Virginia Department of Social Services or any local department of social services which is related to any disposition of founded child abuse/neglect in which I am identified as responsible for such abuse/neglect. I have provided proof of my identity to the Notary Public prior to signing this in his/her presence.

Signature of Person to Be Searched Parents' Signature Needed if child is 17 years old or younger Part IV: CERTIFICATE OF ACKNOWLEDGEMENT OF INDIVIDUAL --

City/County of _______________________ _

Commonwealth/State of ---------------------

Acknowledged before me this _____ day of ----------' 20 ___ _

Notary Public Signature Notary Number

My Commission E?<pires: ----------------------- Do not write below this line.

Part V: Findings - To be completed by OBI Central Registry staff only.

CENTRAL REGISTRY FINDINGS

1. We are unable to determine at this time if the individual for whom a search has been requested is listed in the Central Registry. Please answer the following questions and return to Central Registry Unit in order for us to make a determination:

Worker:--------------- Date:-----------------

2. __ Based on information provided by the Local Department of Social Services, we have determined that

--------------------is listed in the Child Abuse/Neglect Central Registry with a founded disposition of child abuse/neglect. For more detailed information, contact the

--------- Dept.of Social Services in reference to referral ______ ,phone# ____ _

--------- Dept.of Social Services in reference to referral ______ ,phone# ____ _

3 As of this date, based on the information provided, the individual whose name was being searched is NOT identified in the Central Registry Child Abuse/Neglect.

Signature of worker completing search: ---------------Date: -------- OBI staff only

032-02-0 I 51-09-eng ( 11109)

PLEASE NOTE: ALL CHILD PROTECTION REGISTER CHECK FORMS MUST

HAVE ORIGINAL SIGNATURE AND MUST BE HAND-DELIVERY/COURIER OR

MAIL TO:

Ms. Dianne King, Esq.

Attorney Advisor Administrative Services Division DC Courts 616H Street, N.W.

Suite 616

(202) 879-4261

FAX OR E-MAIL COPIES OF THE FORMS WILL NOT BE ACCEPTED.