51a Form - Report Of Child(Ren) Alleged To Be Suffering From Serious Physical Or Emotional Injury By Abuse Or Neglect
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1
2Report of Child(ren) Alleged to be Suffering from
Serious Physical or Emotional Injury by 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.
C
R
HILDREN
EPORTED
Name
Current Location / Address
Sex
Age or Date of Birth
Male
Female
❑
❑
Male
Female
❑
❑
Male
Female
❑
❑
Male
Female
❑
❑
Male
Female
❑
❑
P
G
1
ARENT OR
UARDIAN
Name
First
Last
Middle
Address
Street & Number
City / Town
State
Zip Code
Phone #
Age/Date of Birth
P
G
2
ARENT OR
UARDIAN
Name:
First
Last
Middle
Address:
Street & Number
City / Town
State
Zip Code
Phone #:
Age/Date of Birth
R
/ R
EPORTER
EPORT
Report Date:
Mandatory Report
Voluntary 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 caretaker of report ?
Yes
No
❑
❑
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