CP&P 5-2e
(rev. 10/2006)
State of New Jersey
DEPARTMENT OF CHILDREN AND FAMILIES
Child Protection and Permanency
SCHOOL/DAY CARE REFERENCE
RETURN TO:
(Local Office Address/Sponsoring Agency Address)
ATTENTION:
(Agency Representative)
REGARDING:
(Student) (Grade)
The information given will be kept confidential, unless its disclosure is otherwise required by law or court order.
1. How does the student relate to his/her peers?
2. Does the student display any emotional and/or behavioral problems?
a. [ ] Yes [ ] No If “Yes,” is the child known to the Child Study Team or is a referral in progress/planned?
b. How is this problem(s) being handled?
3. How does the student relate to teachers and/or administration?
4. Are the student’s grades:
[ ] Below Average [ ] Average [ ] Above Average
5. Is the student working to his/her capabilities?
[ ] Yes [ ] No If “No,” please explain.
6. Does the student have a satisfactory attendance record?
[ ] Yes [ ] No If “No,” why not?
THIS FORM IS NOT VALID UNLESS RETURNED DIRECTLY TO CP&P/SPONSORING AGENCY – DO NOT GIVE TO APPLICANT
PLEASE USE THE ENCLOSED RETURN ENVELOPE
7. Have you met the student’s parent(s)? [ ] Yes [ ] No (Who )
Are they (he/she) interested in the student? [ ] Yes [ ] No
Are they (he/she) cooperative with the school? [ ] Yes [ ] No
8. What is the student’s general appearance? (clean, dressed appropriately for weather conditions, rested, etc.)
.
9. Does the student have any disability?
[ ] Yes [ ]No If “Yes,” please explain.
10. Do you feel there are any problems which would preclude this family from providing effective care to a child?
[ ] Yes [ ] No If “Yes,” please explain
COMMENTS:
(Signature)
(Position)
(School) (Date)
THIS FORM IS NOT VALID UNLESS RETURNED DIRECTLY TO CP&P/SPONSORING AGENCY – DO NOT GIVE TO APPLICANT
PLEASE USE THE ENCLOSED RETURN ENVELOPE