Fillable For information about the Sex Offender Registry, visit: (Government of the District of Columbia)

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For information about the Sex Offender Registry, visit: (Government of the District of Columbia)

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This form should only be used for individuals working in DCPS and PCS schools or programs.
August 2021
DC Child Protection Register (CPR) Check Request Instructions
THIS FORM IS ONLY FOR USE BY DCPS AND PCS EMPLOYEES, CONTRACTORS, VOLUNTEERS, INTERNS, STUDENT
TEACHERS, COACHES AND OTHERS WORKING IN THE DISTRICT’S TRADITIONAL AND CHARTER PUBLIC SCHOOLS.
Authorized individuals may request CPR background checks to establish whether an individual has a record of
substantiated abuse or neglect of a child. A CPR check is a civil, not criminal, records check. CPR results are NOT part
of any national registries and must be checked separately in each jurisdiction where the applicant lived or worked.
This application may be used only to determine if abuse or neglect of a child occurred in the District of Columbia.
To request a local police clearance for the District of Columbia, please visit https://mpdc.dc.gov/node/187552.
For information about the Sex Offender Registry, visit: https://mpdc.dc.gov/service/sex-offender-registry.
Requests from a state child welfare agency outside of the District of Columbia, for the history of a family
previously living in the District of Columbia, may call 202-671-SAFE.
Applications will be returned if the correct form is not used.
Get the application from the employer or download a copy of the application form online at
https://cfsa.dc.gov/publication/cpr-request-application-dcps-pcs
Don’t make photocopies of the form; it is updated regularly and old forms may not be accepted.
Applications will be returned if they are not legible or completely filled out.
Typed forms are preferred. If you hand write the form, use block lettering.
Don’t leave any blank spaces: write “no middle name” if you don’t have one, or if a middle name is an
initial only, write “initial only.” If the question is not applicable, write “N/A”.
Applications will be returned if less than 5 years of addresses are provided.
Applicants for employment/volunteering with children in DC must include addresses for the last 5 years.
Even if you don’t live in DC, you must complete this form to work with children in DC.
Applications will be returned if not signed or if ID is not provided.
Applicants must sign the form to give consent for CFSA to release results to the authorized requestor.
A color copy of a government-issued ID must be submitted with the application in order to verify the
applicant’s identity. Only submit the front, back of ID is not needed.
Applications are submitted online: download the fillable PDF application, type it and submit via secure
file upload (mailed, faxed and hand delivered applications are no longer accepted).
Applications may be scanned or photographed with a cell phone or digital camera and submitted online.
CPR check results are not transferrable and can’t be shared from one requester/employer to another.
Results of CPR self-checks may not be used for employment purposes.
Anyone who provides false information may be subject to fines.
Submit applications within 30 days of being filled out to make sure the information is up to date.
Results are provided within 45 days for renewal, 14 days for first-time checks and expedited as needed.
Results sent by encrypted email will expire after 30 days; don’t wait to open the email.
Submit application to DC Department of Human Resources (DCHR) https://dcgov.seamlessdocs.com/f/dchr_cpr_form
If the link is not working, contact dchr.compliance@dc.gov for instructions.
Do not email applications to this address.
QUESTIONS? Contact the CPR unit at 202-727-8885 or CFSA.CPR@DC.GOV, 8:30 AM–4:30 PM Monday through Friday
DC Child & Family Services Agency | 200 I Street SE, Washington, DC 20003 | 202-442-6100 | Facebook/CFSADC | Twitter@DCCFSA
https://cfsa.dc.gov | www.fosterdckids.org | https://dc.mandatedreporter.org
This form should only be used for individuals working in DCPS and PCS schools or programs.
CPR Check Form | obtain the latest form at https://cfsa.dc.gov/publication/cpr-request-application-dcps-pcs | Aug 2021 | Page 1 of 2
DC Child Protection Register (CPR) Check Request Application
Please type or print clearly in block lettering. Sign and date on the last page. Double-check to make sure all information
is complete and legible. Allow up to 45 calendar days for results to be processed. Expedited requests will be considered
on a case-by-case basis. Forms may be returned if incomplete, incorrect, or we can’t read your handwriting.
Date Completed Date Submitted Date Re-submitted
WHAT IS THE REASON FOR THIS CHECK? Information to be provided by the employer
Request
Type
☐
New Hire/Contractor/Volunteer/Intern (first-time check)
Expected start date
☐
Current Employee/Contractor/Volunteer/Intern (renewal check)
Date of last check
WHO IS THE EMPLOYER?
☐
DC Public School (DCPS)
☐
DC Public Charter School (PCS)
Other:
School/program where applicant will work:
WHO WILL RECEIVE THE RESULTS?
Attention To Tamika Cambridge Title Compliance Review Manager
Organization DCHR
Requestor Address
(City/State/Zip)
1015 Half Street SE, Washington DC 30003
Requestor Phone # Requestor Email
Results are sent securely to the authorized requester; they are never provided directly to the employee/applicant.
WHO IS BEING CHECKED? To be completed by the applicant
First Name
Full Middle Name
(write “no middle name” if there is none)
Preferred Phone Number
Email Address
☐
Home
☐
Work
☐
Cell
Date of Birth
(MM/DD/YYYY)
Social Security Number (or USCIS/Alien Registration #)
Sex (on birth certificate)
☐
Male
☐
Female
Other Names Used (nicknames, alias, maiden name, previous married name, legal name change, etc.)
Household Members (List spouse/partner and all children including adoptive, foster, step, students away at college, and adult children)
Name (first name, middle name, last name)
Date of Birth
Relationship to Applicant
Last Name (include suffix if applicable)
CPR Check Form | obtain the latest form at https://cfsa.dc.gov/publication/cpr-request-application-dcps-pcs | Aug 2021 | Page 2 of 2
This form should only be used for individuals working in DCPS and PCS schools or programs.
RESIDENCY INFORMATION. List all addresses and the start and end dates, to the best of your ability.
Applicants for employment or volunteer purposes working in DC must include all addresses of residence for the last five
(5) years, (which may include living on a college campus and receiving mail at parent’s home). Note: to help find previous
addresses, check the credit report bureaus (Equifax, Experian, TransUnion).
Street Address (include Street #, Apt #, Quadrant if applicable)
City, State, Zip
Start Date - End Date
Applications cannot be processed without the required 5 years of address history.
APPLICANT CONSENT
I hereby confirm that I have provided complete and accurate information in this application. I understand that applicants
knowingly providing incomplete or false information may be subject to fines. I consent and authorize the D.C. Child and
Family Services Agency to provide the Requestor (noted on page 1) information concerning me that may be contained in
the Child Protection Register (“CPR”).
Applicant Printed Name
Applicant Signature
Date
APPLICANT IDENTITY VERIFICATION
☐
I will submit a color copy of the front of a government-issued, photo identification document with this application
(MM/YYYY – MM/YYYY)
(Example) 123 Jay Street NW, Apt. 1A
Washington DC, 20000
10/2016-present
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For information about the Sex Offender Registry, visit: (Government of the District of Columbia)

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Completed 3 June 2022

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