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Instruction

CFSA COVID-19 No Contact Assistance Referral Form
Fields marked with * are required
TIPS FOR COMPLETING CFSA ABSENTEEISM REPORTING FORM
This form may be used to report concerns about students (ages 5 to 13) that result from their lack of contact with the school system during the COVID-19 Pandemic/ Distance Learning Period.

***This form should not be used to report suspicions of abuse or neglect. All concerns of abuse or neglect should be reported through the CFSA hotline at 202-671-SAFE(7233)***.
Call 911 or the Hotline.

Use one form per family. Do not use the same form to report children from different families.Please fill out the form completely and provide an answer for each requested response. Failure to complete the form in its entirety will result in the denial of the form.Failure of schools to complete sufficient efforts to contact families will result in a denial of the form.Questions or concerns should be directed to the Triage Supervisor- Joseph Osiecki (202)727–7807 joseph.osiecki@dc.gov
Select Yes if the school, other students/families, community service providers have had no contact (Virtual, face-to-face, verbal, etc) with the student during the last 10 school days and the identified child has not participated in any level of distance learning. *
Attachment Name
Attachment Description
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Is this family currently homeless?
Optional Attachment
Attachment Name
Attachment Description
Attachment
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Reporter Information

CFSA COVID-19 No Contact Assistance Referral Form
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Details

Suspicions of abuse or neglect must be reported through the Hotline at 202-671-SAFE (7233). DO NOT USE THIS FORM IF YOU SUSPECT THAT A CHILD IS IN IMMEDIATE DANGER, Call 911 or the Hotline.
Please enter your Name
Time available to answer follow up questions
School Address
Teacher Information

Parent/Guardian/Custodian Information

CFSA COVID-19 No Contact Assistance Referral Form
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Details

Please enter your Parent's name
Date of Birth
Race/Ethnicity
Parent/Guardian/Custodian Address
Is this Phone working or not working?

Child Information

CFSA COVID-19 No Contact Assistance Referral Form
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Details

Please enter Child's name
Date of Birth
Race/Ethnicity
**This section is to indicate how long it has been since last contact with student**
Do you have concerns for this identified student(s) outside of non-participation in distance learning? *

Questions and Responses

CFSA COVID-19 No Contact Assistance Referral Form
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Interventions

Telephone

Were TELEPHONE calls made to the family (this should include calls to emergency contacts, family members and all other contact persons who could potentially help in locating the identified student

Letters

Were LETTERS mailed to the family? *

MPD/Other Welfare Checks

Was MPD or another partner contacted to complete a Welfare Check of this student? *

Home Visits

Were HOME VISITS conducted by DCPS/DCPCS Staff?

Referrals

Workflow

CFSA COVID-19 No Contact Assistance Referral Form
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Public User

Supervisor/Program Manager

Triage Worker

Was this case a Screen In or Screen Out
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