Report Of Suspected Child Abuse Or Neglect Form - North Dakota Department Of Human Services
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1REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT
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NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
CHILDREN AND FAMILY SERVICES
SFN 960 (6-2015)
Name of Child(ren)
Age or Birthdate
Name of Child(ren)
Age or Birthdate
IDENTIFYING INFORMATION
Name of Parent(s)/Caretaker
Telephone Number
Address
City
State
ZIP Code
Name of Subject (Person(s) Suspected to be Causing Maltreatment)
Telephone Number
Address
City
State
ZIP Code
Give nature and extent of the suspected abuse or neglect, including any information of previous abuse or neglect; family composition; and
any other information which may be helpful in protecting the health and welfare of the child(ren). If additional space is needed, attach
additional pages. (BE SPECIFIC. ANSWER WHO, WHAT, WHEN, WHY, HOW OFTEN).
Name of Reporter
Reporter's Relationship to Children
Telephone Number
Address
City
State
ZIP Code
Signature of Reporter
Date
AGENCY USE ONLY
Date and Time Received by Agency
Name of Intake Social Worker
Source
Date of Entry
Report Number
Assessment Number
Case Number
Name of Social Worker Assigned to Case
Received By
Initial Category
In Person
Telephone
Written
A
B
C
Please submit the completed form to the county social service office where the child is currently physically located. Contact
information for county social service offices can be found at:
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