Fillable To request a local police clearance for the (Government of the District of Columbia)

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To request a local police clearance for the (Government of the District of Columbia)

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Country of origin: US
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U.S.A. forms for Government of the District of Columbia

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October 2021
DC Child Protection Register (CPR) Check Request Instructions
EMPLOYEES, CONTRACTORS, VOLUNTEERS, INTERNS, STUDENT TEACHERS, COACHES AND OTHERS WORKING IN THE DISTRICT’S
TRADITIONAL OR CHARTER PUBLIC SCHOOLS SHOULD USE FORMS AND FOLLOW INSTRUCTIONS SPECIFIED BY THE SCHOOL'S
RECRUITMENT AND HIRING OR HUMAN RESOURCES POINT OF CONTACT.
A DC CPR check is done to determine if an individual has a record of substantiated abuse or neglect of a child that
occurred in the District of Columbia only. A CPR check is a civil, not criminal, check. CPR results are NOT part of any
national registries and must be checked separately in each jurisdiction where the applicant lived or worked.
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.
Get the current application from the employer or child placing agency or download a copy of the
application form online at https://cfsa.dc.gov/service/child-protection-register-cpr
.
Don’t use photocopies of the form; it is updated regularly and old forms may not be accepted.
Applications may 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 the required years of addresses are provided.
DC law requires applicants for employment, back-up caregivers, adult household members, and subsidy
recipients to provide five (5) years of address history. Applicants for a foster care, kinship or adoption
license must list District of Columbia addresses going back to 2002.
Applicants must sign the form to give consent for CFSA to release results to the authorized requestor.
Applications won’t be processed if an ID is not provided. A color copy of a government-issued, photo
identification must be submitted with the application in order to verify the applicant’s identity. Only
submit the front, the back of the ID is not needed.
Applications are submitted online via secure file upload at https://cfsa.dc.gov/service/child-protection-
register-cpr (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.
Name application in this format: firstname-lastname-app-submission-date (e.g., John-Doe-App-10-15-2021)
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, expedite requests are
c
onsidered on a case-by-case basis.
Results are sent by encrypted email and will expire after 30 days; don’t wait to open the email.
Submit renewal requests 45-60 days prior to the expiration date of the last clearance. Know your renewal period. DC
renewal terms are: three (3) years for childcare providers, two (2) years for educators and youth workers, one (1) year
for adoption, foster care and subsidy recipients, or as otherwise designated by law, regulation or contract terms.
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
Don’t
use an old form; get the current form at https://cfsa.dc.gov/service/child-protection-register-cpr | Rev. Oct 2021 | Page 1 of 2
DC Child Protection Register (CPR) Check Request Application
This is a “fillable” PDF form. Download it on your computer, save it with applicant name and submission date: “John-Doe-
App-10-01-2021” (no periods, punctuation, special characters or spaces in the file name). Type this form. If you print it and
handwrite, print clearly in block lettering. Forms are returned if incomplete, incorrect or the handwriting is not clear.
I.
THE REQUESTOR COMPLETES THIS SECTION
☐ NEW REQUEST (The applicant does not have a CPR clearance on file with this requestor)
Date Needed
☐ RENEWAL REQUEST (The applicant has a CPR clearance on file with this requestor)
Date
of Last Results
Please call 202-727-8885 or email cfsa.cpr@dc.gov for special circumstances needing expedited results.
Request Purpose: Check Only One (if unsure, contact the CPR office at 202-727-8885 or cfsa.cpr@dc.gov)
Employment
☐ Employment suitability determination (employee/contractor/sub-contractor/volunteer/fellow/intern)
Child Welfare
☐ Household Member or Back-Up Caregiver
☐ Grandparent/Relative Caregiver Program Subsidy
☐ Investigation, Court, Custody Determination
Self-check
☐ Personal Use (may not be used for employment, child welfare or licensing purposes)
Contact Name/Title
Organization Name
Requestor Address
Requestor Phone # Requestor Email
If the employer has a contract/sub-contract with a DC Gov’t agency, list the agency here
Results are sent to the requestor by encrypted email. The encrypted email link will expire 30 days after it is sent. Please check the
email junk or spam folder if you have not received the results within 14 days for new hires or 45 days of the request date for others.
II. THE APPLICANT COMPLETES THIS SECTION
Last Name
(include suffix if applicable)
First Name
Middle Name
(type "no middle name" if none)
Preferred Phone Number
Email Address
Date of Birth
(MM/DD/YYYY)
Social Security Number
(or USCIS/Alien Registration #)
Sex
(on birth certificate)
Other Names Used and Type of Name (maiden name, previous married name, legal name change, nicknames, alias, etc.)
Name
Type
Name
Type
Name
Type
Name
Type
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
Home Work Cell
Male
Female
D
on’t use an old form; get the current form at https://cfsa.dc.gov/service/child-protection-register-cpr | Rev. Oct 2021 | Page 2 of 2
RESIDENCY INFORMATION. List all addresses, and the start and end dates, to the best of your ability.
Applicants for employment purposes working in DC must include all addresses of residence for the last five (5) years.
Back-up caregivers, adult household members, subsidy recipients and individuals requesting a self-check living in DC
must include all addresses of residence for the last five (5) years.
Applicants for adoption, guardianship, foster care, and kinship care must provide all District of Columbia addresses going
back to 2002, per the Improved Child Abuse Investigations Amendment Act of 2002, D.C. Law 14-206, § 4–1302.03.
To help remember your previous addresses, check the credit report bureaus (Equifax, Experian, TransUnion).
Street Address (Include Quadrant and Apt # if applicable) City, State, Zip
Start – End Dates
(MM/YYYY – MM/YYYY)
(EXAMPLE) 100 J Street NW, Apt. B Washington, DC 20000 10/2016-present
APPLICANT CONSENT & IDENTITY VERIFICATION
I hereby confirm that I have provided complete and accurate information. I understand that if I knowingly provide
incomplete or false information, I may be subject to fines. I consent and authorize the D.C. Child and Family Services
Agency to provide the Requestor information about me that may be contained in the Child Protection Register (“CPR”).
Applicant Printed Name
Applicant Signature
Date
☐
I will submit a color copy of the front of a government-issued, photo identification document with this application
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To request a local police clearance for the (Government of the District of Columbia)

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Completed 14 January 2022

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