Report Of Child(Ren) Alleged To Be Suffering From Abuse Or Neglect (Page 2 of 3) in pdf

Report Of Child(Ren) Alleged To Be Suffering From Abuse Or Neglect Page 2

PARENT, GUARDIAN OR CARGIVER 2

Name:

First

Last

Middle

Address:

Street & Number

City / Town

State

Zip Code

Phone #:

Age/Date of Birth:

Language Spoken:

Relationship to Child(ren):

REPORTER / REPORT

Report Date:

Mandatory Report

Non Mandatory Report

Reporter’s Name:

First

Last

Middle

(If the reporter represents an institution, school or facility, please indicate)

Reporter’s Address:

Street & Number

City / Town

State

Zip Code

Phone #:

Has reporter informed caregiver of report ?

Yes

What is the reporter’s relationship to the child(ren)?

What is the nature and extent of injury, abuse, maltreatment or neglect? Please list any prior evidence of same and/or other worries regarding

danger to the child(ren). (Please cite the source of this information if not observed firsthand.)

CONCERNS: Please check all that apply.

☐ Substance Use/Misuse

☐ Acute/Chronic Medical Condition

☐ Runaway

☐ Gang Involvement

☐ Substance Exposed Newborn

☐ Housing Instability/Homelessness

☐ Neonatal Abstinence Syndrome

☐ Human Trafficking

☐ None Applies

☐ Domestic Violence

☐ Sexual Exploitation

☐ Unknown

☐ Mental/Behavioral Health Challenges

☐ Teen Parenting

☐ Other

DESCRIPTION OF RELATED CONCERNS: Please include additional information that will help DCF further understand the concerns checked above. This

includes any specific concerns about alcohol/drug use by the parent/guardian/caregiver. If there are concerns related to domestic violence, please also list any

information that will help DCF make safe contact with the family (e.g., work schedule, place of employment, daily routines for the adult victim, etc.).

If known, please provide the name(s) and address, phone #, DOB/age, relationship to child, and language spoken of the person(s) responsible

for the injury, abuse, maltreatment or neglect and/or any other information that you think might be helpful in establishing the cause of the injury,

abuse, maltreatment or neglect.