Report Of Child(Ren) Alleged To Be Suffering From Abuse Or Neglect printable pdf download

Report Of Child(Ren) Alleged To Be Suffering From Abuse Or Neglect

Report of Child(ren) Alleged to be Suffering from

Abuse or Neglect

Massachusetts law requires mandated reporters to immediately make a report to the Department of Children and Families (DCF)

when they have reasonable cause to believe that a child under the age of 18 years is suffering from abuse and/or neglect by:

STEP 1: Immediately reporting by oral communication to the local DCF Area Office (see contact information at end of

form); and

STEP 2: Completing and sending this written report to the local DCF Area Office within 48 hours of making the oral report.

For more information about requirements for mandated reporters and filing a report of alleged abuse and/or neglect please see A

Guide for Mandated Reporters available on the DCF website at

Please complete all sections of this form. If some data is uncertain or unknown, please signify by placing a question mark (“?”) after the entry.

CHILDREN REPORTED

Name

Current Location/Address

Language Spoken

Birth Sex

Age or

ICWA/Tribal

Date of Birth

Affiliation

Male

Female

EMERGENCY CONTACT(S) FOR CHILDREN REPORTED: Please list the emergency contact information for all of the reported children, including contact

name, relationship, and contact number information.

OTHER CHILDREN: Please include information about other children in the home/family, including name and age/date or birth (if known).

PARENT, GUARDIAN OR CAREGIVER 1

Name:

First

Last

Middle

Address:

Street & Number

City / Town

State

Zip Code

Phone #:

Age/Date of Birth:

Language Spoken:

Relationship to Child(ren):

Report Of Child(Ren) Alleged To Be Suffering From Abuse Or Neglect