Report Of Actual Or Suspected Child Abuse Or Neglect Form - State Of Michigan

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REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT
Michigan Department of Human Services
Was complaint phoned to DHS?
Yes
No
If yes,
Log #
If no, contact Centralized Intake (855-444-3911) immediately
1. Date
INSTRUCTIONS: REPORTING PERSON: Complete items 1-19 (20-28 should be completed by medical personnel,
if applicable). Send to Centralized Intake at the address list on page 2.
2. List of child(ren) suspected of being abused or neglected (Attach additional sheets if necessary)
NAME
BIRTH DATE
SOCIAL SECURITY #
SEX
RACE
3. Mother’s name
4. Father’s name
5. Child(ren)’s address (No. & Street)
7. County
8. Phone No.
6. City
9. Name of alleged perpetrator of abuse or neglect
10. Relationship to child(ren)
11. Person(s) the child(ren) living with when abuse/neglect occurred
12. Address, City & Zip Code where abuse/neglect occurred
13. Describe injury or conditions and reason for suspicion of abuse or neglect
14. Source of Complaint (Add reporter code below)
01 Private Physician/Physician’s Assistant
13 School Administrator
45 Private Agency Social Worker
02 Hosp/Clinic Physician/Physician’s Assistant
14 School Counselor
46 Court Social Worker
03 Coroner/Medical Examiner
21 Law Enforcement
47 Other Social Worker
04 Dentist/Register Dental Hygienist
22 Domestic Violence Providers
48 FIS/ES Worker/Supervisor
05 Audiologist
23 Friend of the Court
49 Social Services Specialist/Manager (CPS, FC, etc.)
06 Nurse (Not School)
25 Clergy
51 Hospital/Clinic Personnel
07 Paramedic/EMT
31 Child Care Provider
52 DHS Facility Personnel
08 Psychologist
41 Hospital/Clinic Social Worker
53 DMH Facility Personnel
09 Marriage/Family Therapist
42 DHS Facility Social Worker
54 Other Public Social Agency Personnel
10 Licensed Counselor
43 DMH Facility Social Worker
55 Private Social Agency Personnel
11 School Nurse
44 Other Public Social Worker
56 Court Personnel
12 Teacher
15. Reporting person’s name
Report Code (
) 15a. Name of reporting organization (school, hospital, etc.)
see above
15b. Address (No. & Street)
15c. City
15d. State 15e. Zip Code
15f. Phone No.
16. Reporting person’s name
Report Code (
) 16a. Name of reporting organization (school, hospital, etc.)
see above
16b. Address (No. & Street)
16c. City
16d. State 16e. Zip Code
16f. Phone No.
17. Reporting person’s name
Report Code (
) 17a. Name of reporting organization (school, hospital, etc.)
see above
17b. Address (No. & Street)
17c. City
17d. State 17e. Zip Code
17f. Phone No.
18. Reporting person’s name
Report Code (
) 18a. Name of reporting organization (school, hospital, etc.)
see above
18b. Address (No. & Street)
18c. City
18d. State 18e. Zip Code
18f. Phone No.
19. Reporting person’s name
Report Code (
) 19a. Name of reporting organization (school, hospital, etc.)
see above
19b. Address (No. & Street)
19c. City
19d. State 19e. Zip Code
19f. Phone No.
DHS-3200 (Rev. 2-12) Previous edition may be used. MS Word
1

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