Report Of Actual Or Suspected Child Abuse Or Neglect Form - State Of Michigan Page 2
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2TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE
20. Summary report and conclusions of physical examination (Attach Medical Documentation)
21. Laboratory report
22. X-Ray
23. Other (specify)
24. History or physical signs of previous abuse/neglect
YES
NO
25. Prior hospitalization or medical examination for this child
DATES
PLACES
26. Physician’s Signature
27. Date
28. Hospital (if applicable)
Department of Human Services (DHS) will not discriminate against any individual or group
AUTHORITY:
P.A. 238 of 1975.
because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual
COMPLETION:
Mandatory.
orientation, gender identity or expression, political beliefs or disability. If you need help with
PENALTY:
None.
reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make
your needs known to a DHS office in your area.
INSTRUCTIONS
GENERAL INFORMATION:
This form is to be completed as the written follow-up to the oral report (as required in Sec. 3 (1) of 1975 PA 238, as amended) and mailed
to Centralized Intake for Abuse & Neglect. Indicate if this report was phoned into DHS as a report of suspected CA/N. If so, indicate the Log
# (if known). The reporting person is to fill out as completely as possible items 1-19. Only medical personnel should complete items 20-28.
Mail this form to:
Centralized Intake for Abuse & Neglect
th
5321 28
Street Court S.E.
Grand Rapids, MI 49546
OR
Fax this form to 616-977-1154 or 616-977-1158
Or email this form to
DHS-CPS-CIGroup@michigan.gov
1.
Date – Enter the date the form is being completed.
2.
List child(ren) suspected of being abused or neglected – Enter available information for the child(ren) believed to be abused or
neglected. Indicate if child has a disability that may need accommodation.
3.
Mother’s name – Enter mother’s name (or mother substitute) and other available information. Indicate if mother has a disability that
may need accommodation.
4.
Father’s name – Enter father’s name (or father substitute) and other available information. Indicate if father has a disability that may
need accommodation.
5.-7. Child(ren)’s address – Enter the address of the child(ren).
8.
Phone – Enter phone number of the household where child(ren) resides.
9.
Name of alleged perpetrator of abuse or neglect – Indicate person(s) suspected or presumed to be responsible for the alleged abuse
or neglect.
10. Relationship to child(ren) – Indicate the relationship to the child(ren) of the alleged perpetrator of neglect or abuse, e.g., parent,
grandparent, babysitter.
11. Person(s) child(ren) living with when abuse/neglect occurred – Enter name(s). Indicate if individuals have a disability that may need
accommodation.
12. Address where abuse / neglect occurred.
13. Describe injury or conditions and reason of suspicion of abuse or neglect – Indicate the basis for making a report and the information
available about the abuse or neglect.
14. Source of complaint – Check appropriate box noting professional group or appropriate category.
Note: If abuse or neglect is suspected in a hospital, also check hospital.
DHS Facility – Refers to any group home, shelter home, halfway house or institution operated by the Department of Human Services.
DCH Facility – Refers to any institution or facility operated by the Department of Community Health.
15.-19 - Reporting person’s name - Enter the name and address of person(s) reporting this matter.
DHS-3200 (Rev. 2-12) Previous edition may be used. MS Word
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