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GOVERNMENT OF THE DISTRICT OF COLUMBIA
Child and Family Services Agency
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Instruction

CFSA Educational Neglect Reporting Form
Fields marked with * are required
TIPS FOR COMPLETING CFSA ABSENTEEISM REPORTING FORM
This form may be used to report suspicions of educational neglect. All other 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.
This form may be used to report concerns of educational neglect for children between the ages of 5 and 17 years old. Any other suspicions of abuse or neglect should be reported to the Hotline at 202-671-SAFE (7233). Use one form per family. Do not use the same form to report children from different families. Please identify all children in the family/ household that are known (even if you are not reporting attendance concerns for the other child(ren). Please fill out the form completely and provide an answer for each requested response. ALL REPORTS MUST INCLUDE A COPY OF ATTENDANCE RECORDS, REPORT CARD AND ALL OTHER SUPPORTING DOCUMENTS. Questions or concerns should be directed to the Triage Supervisor- Joseph Osiecki (202)727–7807 joseph.osiecki@dc.gov
Select Yes if the child(ren) you are reporting is currently absent and there has been no contact for a week or more. *
Mandatory Documentation
ALL REPORTS MUST INCLUDE A COPY OF ATTENDANCE RECORDS, REPORT CARD AND ALL OTHER SUPPORTING DOCUMENTS. *
*Please check each box to confirm that the requested information is attached*
Attachment Name
Attachment Description
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Attachment
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Attachment Description
Attachment Name
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Reporter Information

CFSA Educational Neglect Reporting Form
Fields marked with * are required

Details

This form may be used to report suspicions of educational neglect. All other 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
School Address

Parent/Guardian/Custodian Information

CFSA Educational Neglect Reporting Form
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Details

Please enter your Parent's name
Date of Birth
Race/Ethnicity
Parent/Guardian/Custodian Address

Child Information

CFSA Educational Neglect Reporting Form
Fields marked with * are required

Details

Please enter Child's name
Date of Birth
Race/Ethnicity
Is the child(ren) identified for special services (e.g. physical, behavioural, developmental or emotional)? *

Questions and Responses

CFSA Educational Neglect Reporting Form
Fields marked with * are required

Telephone

Were TELEPHONE calls made to the family? *

Letters

Were LETTERS mailed to the family? *

Meetings

Were MEETINGS scheduled with the family? *

Home Visits

Were HOME VISITS conducted? *

Referrals

Workflow

CFSA Educational Neglect Reporting Form
Fields marked with * are required

Public User

Supervisor/Program Manager

Social Worker

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GOVERNMENT OF THE DISTRICT OF COLUMBIA
Child and Family Services Agency
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Child and Family Services Agency