This form is for Early Learning Program providers who have agreements with Workforce Solutions for North Central Texas to report
5-day consecutive absences of children enrolled in the TWC subsidy program. Do not submit this form if the child has been absent for fewer than 5 consecutive days. 

Select County from the drop-down menu first to filter the list of providers. Contact information will be populated with data on file; make any changes to name or phone number before submitting the form.

County*  
Provider Name* (CCS Provider Number)
Authorized Representative Name*
Phone Number*

Complete the form below for all children with 5 consecutive absences.

Child 1
Child Name* Parent/Caregiver Name*
Date of First Absence* Date of Last Absence*
CPS Case*

 
Reason for Absence*
Child 2
Child Name Parent/Caregiver Name
Date of First Absence Date of Last Absence
CPS Case

 
Reason for Absence
Child 3
Child Name Parent/Caregiver Name
Date of First Absence Date of Last Absence
CPS Case

 
Reason for Absence
Child 4
Child Name Parent/Caregiver Name
Date of First Absence Date of Last Absence
CPS Case

 
Reason for Absence
Child 5  
Child Name Parent/Caregiver Name
Date of First Absence Date of Last Absence
CPS Case

 
Reason for Absence