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
___________ __________
Day Year
Social Security No. ________--______--________ Gender: Male Female
Race: ______________________________________
List all names ever used (maiden, married, alias, etc.; continue on additional pages if needed): _________________________________________________________________________________________
Last First Middle
_________________________________________________________________________________________
Last First Middle
_________________________________________________________________________________________
Last First Middle
_________________________________________________________________________________________
Last First Middle
_________________________________________________________________________________________
Last First Middle
Request for a Child Protection Register Check Revised – June 3, 2008
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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 _________________________________ _________________________________________________ Signature Name of CFSA employee (print): _____________________________________ Title: _____________________________________________ ID # _______________________
Request for a Child Protection Register Check Revised – June 3, 2008
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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 Revised – June 3, 2008
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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 400 6th Street, SW Washington, DC 20024 Attn: Child Protection Register
TO BE COMPLETED BY REFERRING AGENCY REQUESTING RESPONSE VIA MAIL:
Agency Name: Email Address (optional): Address: State:
DC
TO BE COMPLETED BY REFERRING AGENCY REQUESTING RESPONSE VIA FAX: Please fax the response to: Attention: Fax Number
Baylor, Tameka Higher Achievement
(Agency Name) (Designated Agent)
202-544-3644
********************************************************************************************************************************* I UNDERSTAND THAT I WILL NOT RECEIVE AN ORIGINAL COPY IN THE MAIL IF I REQUEST A TB FAXED COPY. ________ (Initials)
Request for a Child Protection Register Check Revised – June 3, 2008
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Statement of Accuracy and Authorization for Background Check The information I have provided in this application (and accompanying resume, if any) is true, correct and complete to the best of my knowledge. False, incomplete or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment, regardless of the time elapsed after discovery. I authorize the employer to contact and obtain information about me from previous employers, educational institutions and "references" I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my application, I waive rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose. This release shall remain in effect for the length of my employment. I understand that according to federal law all individuals who are hired must, as a condition of employment, produce certain documentation to verify their identity and U.S. citizen status or, if aliens, their legal authorization to work in the U.S. As a consequence, I understand that any offer of employment would be contingent on my ability to produce the required documentation within the time period required by law. Higher Achievement conducts background checks on its staff, both paid and volunteer. Your employment with Higher Achievement is contingent on a determination that your background does not include felonies or other criminal charges that would be inappropriate for individuals working with youth. Have you been convicted of a felony which has not been annulled, expunged or sealed by a court? Conviction of a crime is not an automatic bar to employment. All circumstances will be considered. Yes No If yes, describe in full on reverse. Date: ________________________________ Social Security Number: ___________________
Signed: _________________________________ Name: __________________________________ Date of Birth:
Home Address: ________________________________________________________________
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◊ ◊
Background check completed, no relevant findings.
Date: ___________________
Signed: ___________________________________________
Background check completed, with findings (see attached)
Date: ___________________
Date: ___________________
Signed by Executive Director: ___________________________________ Date: ___________________
Volunteer Application
(revised 3/29/11)
Thank you for your interest in volunteering in the District of Columbia Public Schools (DCPS). Each year, thousands of motivated individuals like you use their skills, resources and knowledge to impact student achievement in DCPS.
Volunteer Application Processing & Fingerprinting Hours: Tuesdays and Thursdays, 9 a.m. – 3:30 p.m., or by appointment Bring the below documents to the Volunteer Coordinator at 1200 First Street NE, 12 Floor, Washington, DC 20002. After your application is approved, you will be directed to our fingerprinting office. 1. Tuberculosis (TB) Verification (provided by applicant, taken within one year of the application date) 2. Completed DCPS Volunteer Application 3. State issued photo identification (example: passport, drivers license, government ID) th You will receive a verification letter at the address listed on your application in approximately 5 – 10 business days after completing fingerprinting. Bring the verification letter to your school as proof of clearance. If we can be of any further assistance, please contact the Volunteer Coordinator at dcpsvolunteers@dc.gov or 202-442-5447. Additional forms and information are available at http://www.dcps.dc.gov/DCPS/volunteer Middle and high school students: Do not complete this volunteer application. Please download or request a “student volunteer application.” If you have an active federal security clearance: Please download or request a “federal security clearance verification form” and submit it with your application in lieu of the fingerprinting requirement. Groups of 20 or more volunteers: Please contact the fingerprinting office at 202-442-5043 to inquire about scheduling a fingerprinting session at your location. A volunteer clearance is valid for 2 years. The criminal background investigation code set by the District of Columbia states: “Background checks shall be conducted for all DCPS employees/unsupervised volunteers at least every two years.” Volunteers must comply with this code and make immediate disclosure in writing to DCPS of any arrests or convictions.
Volunteer Statement of Commitment
(Retain for your records)
As a volunteer working in the District of Columbia Public Schools (DCPS), I agree to: Sign In and Out at the designated place during each visit. Identity myself as a volunteer. Receive and wear a badge or nametag provided by the front office to ensure school safety. This will ensure that you are acknowledged as a contributing member of the school team during your volunteer time. Attend a volunteer orientation when they are offered to become familiar with DCPS policies, procedures and best practices. Honor the commitment to work as scheduled. If you have a child in DCPS, please do not use your volunteer time to speak to your child’s teacher or other staff members about your child. Schedule an appointment to address concerns related to your child. Notify the DCPS representative assigned to work with me if I must be absent from a volunteer commitment. Abide by all the school rules and DCPS policies and regulations that are applicable to me. Maintain the confidentiality of any information I learn during volunteer work. When you discuss student needs with teachers, you may learn some personal information. Such information must remain confidential and must not be discussed, except with appropriate staff members as needed. Inform appropriate staff members (teachers, school counselor and school principal) if I suspect or learn that a child is in danger or exposed to any type of abuse or neglect.
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Criminal Background Check Fingerprinting Verification and Disclosure Form
Personal Information
Name: (Last) Maiden and/or Prior Name(s): Current Mailing Address: City: (First) (Middle)
Washington New Hire Promotion
State: DC Email:
Zip Code:
20006
Telephone: Check: Date: Volunteer Placement (DCPS school name):
Volunteer
Designator
Summer
Other
Criminal Background Information – You must answer each question in this section before we can process your application
When answering the following questions you may omit: (1) traffic fines; (2) any violation of law committed before your 18 birthday, if finally decided in juvenile court or under a youth offender law; (3) any conviction set aside under the Federal Youth Corrections Act or similar state law; and (4) any conviction whose record was expunged under federal, state, or local law. We will consider the date, facts, and circumstances of each event you list. 1. 2. Convictions: Have you ever (except as stated above) been convicted of any criminal offense? If “Yes” continue to Question 2. If “No” continue to Question 5. Explanation of Convictions: Please give the following details for each conviction: (date of offense, charge(s) you were convicted of, place of violation, sentence/incarceration length, any additional information necessary): th Yes
No
3.
Probation/Parole/Supervised Release: Are you currently on probation, supervised/unsupervised release from prison, or parole?
Yes
No
If “Yes” please state: (1) start/end dates; (2) conditions of probation/release/parole.
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Criminal Background Check (continued)
4. Pardons: If you received a pardon(s) for one or more of your criminal convictions, review the law concerning pardons in the state where you received your pardon. Some states require you to report a conviction even if it you have received a pardon. If you are required to disclose a pardoned offense please do so here.
5.
Pending Criminal Charges: List and describe any pending criminal charge(s)/case(s) against you (no time limitation):
United States Armed Services
Have you ever been discharged from the Armed Services under other than Honorable conditions?
Yes
No
If “Yes,” please provide the following details: date of offense, charge(s) you were convicted of, place of violation, sentence/incarceration length, any additional information necessary.
Signature, Certification, and Release of Information
YOU MUST SIGN THIS APPLICATION READ CAREFULLY BEFORE SIGNING I understand that a false statement on any part of my application may be grounds for not hiring me, or for firing me after I begin work (D.C. Official Code § 1-616.51 et seq.) (2001). I understand that the making of a false statement on this form or materials submitted with this form is punishable by criminal penalties pursuant to D.C. Official Code § 22-2405 et seq. (2001). I understand that any information I give may be investigated as allowed by law or Mayoral order. I consent to the release of information regarding my suitability for District of Columbia Government employment by employers, schools, law enforcement agencies, and other individuals and organizations; to investigators, personnel staffing specialists, and other authorized employees of the District of Columbia government. I certify that, to the best of my knowledge and belief, all of my statements are true, correct and complete.
Criminal Background Check Affirmation
Please read the listed offenses and then circle the appropriate declarations in the next section. (1) Murder, attempted murder, manslaughter, or arson; (2) Assault, assault with a dangerous weapon, mayhem, malicious disfigurement, or threats to do with bodily harm; (3) Burglary; (4) Robbery; (5) Kidnapping; (6) Illegal use or possession of a firearm; (7) Sexual offenses, including indecent exposure; promoting, procuring, compelling, soliciting, or engaging in prostitution; corrupting minors (sexual relations with children); molesting; voyeurism; committing sex acts in public; incest; rape; sexual assault; sexual battery; or sexual abuse; but excluding sodomy between consenting adults; (8) Child abuse or cruelty to children; or (9) Unlawful distribution of or possession with intent to distribute a controlled substance.
DIRECTIONS: CIRCLE ONE DECLARATION TO COMPLETE AND AFFIRM EACH STATEMENT I have / I have not been convicted of any of the above listed offenses or their equivalent either in the District of Columbia, or in any other state or territory. pleaded nolo contendere to any of the above listed offenses or their equivalent, either in the District of Columbia, or in any state or territory. on probation before judgment or placed upon a stet docket of a case involving any of the felony offenses listed above. been found not guilty by reason of insanity for any of the above listed offenses or their equivalent, either in the District of Columbia, or in any state or territory.
I have/ I have not
I am / I am not
I have / I have not
AFFIRMATION I hereby affirm my responsive declaration to each statement on this Affirmation form. _______________________________________________________ Signature ________________________________________ Date
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Acknowledgment of Receipt
I have been informed that the District of Columbia Public Schools is subject to, and authorized to conduct a criminal background check on me, and may choose to deny employment or a volunteer position to me, or terminate my employment or volunteer positions, based on the outcome of the criminal background check. I have been informed of my right to obtain a copy of the criminal background check report and to challenge the accuracy and completeness of that report.
Volunteer Placement Information
DCPS School Name _______________________________________________________________________________________________ Referred by (individual or organization name): ____________________________________________________________________ Type of applicant (circle one): Community Volunteer Parent Volunteer UELIP Intern Other: __________________
If you are a parent, please list the DC Public Schools school(s) your child/children attend: __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
Acknowledgment of Risks, Assumption of Risks, and Release/Waiver Agreement for DCPS Volunteer Activities PLEASE READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING.
I acknowledge and agree as follows:
1. 2. I have read and will abide by the Volunteer Statement of Commitment. That I must sign the District of Columbia Public Schools' (DCPS) Acknowledgement of Risks, Assumption of Risks, and Release/Waiver Agreement before participating in the DCPS volunteer activity listed above. 3. That if I am the parent or legal guardian of a child under 18, I must sign a separate Acknowledgement of Risks, Assumption of Risks, and Release/ Waiver Agreement for the child before they can participate in the volunteer activity listed above. 4. That some of the activities include risks that may cause or lead to injuries to volunteers. I understand that DCPS staff, employees or other personnel cannot assure volunteers' safety or eliminate these risks. I am voluntarily participating with knowledge of the risks. Therefore, I assume and accept full responsibility for the risks of this activity (both known and unknown), and for any injury, damage, or other loss suffered by me, resulting from those risks. 5. That I will perform only those tasks assigned, observe all safety rules, and use care in the performance of my assignments. 6. That I will perform assigned tasks which are within my physical capability to the best of my ability, and that I will not undertake tasks that are beyond my ability or physical capability. 7. That I am familiar with the safe operation and use of equipment and tools that I may utilize in connection with this volunteer activity, and that I will not undertake to use any equipment or tools with which I am unfamiliar or do not know how to operate safely. 8. That I am volunteering my services for the activity listed above on a voluntary basis without anticipation of payment or compensation of any kind. 9. That I agree to release and not to sue DCPS in regard to all claims, liabilities, suits, or expenses (hereafter collectively claim or claims), including claims caused or alleged to be caused by the negligence of DCPS, for any injury, damage, or other loss to me in any way connected with my participation in this activity, or my use of DCPS equipment or facilities. I understand that I agree to waive all claims I may have against DCPS, and agree that neither I, nor anyone acting on my behalf, will make a claim or file a lawsuit against DCPS. 10. That I hereby agree to discharge, indemnify and hold harmless, DCPS, all sponsors, and participating volunteer organizations, and their agents, employees and representatives, from all claims, demands, actions or judgments which I, or my heirs, executors, administrators or assigns may have for any and all injuries and damages, known or unknown, caused by or arising out of the activity listed above. 11. That I specifically acknowledge that I am engaging in this activity as a volunteer, at my own request and risk, and not as an employee of DCPS or their sponsors, and further acknowledge that I am not entitled to any compensation, benefit or insurance coverage from DCPS or their sponsors, nor will I make such claim. 12. That I have carefully read, understand and voluntarily sign this document and acknowledge that it shall be effective and binding upon me, my minor children and other family members, and my heirs, executors, representatives and estate.
Any portion of this Document deemed unlawful or unenforceable shall not affect the remaining provisions, and those remaining provisions shall continue in full force and effect. Name (Print): _________________________________Signature:___________________________________ Date: ______________ Emergency Contact Name/Phone Number: ________________________________________________________________________
