Suspected Child Abuse Reporting Form

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Iowa Department of Human Services
SUSPECTED CHILD ABUSE REPORTING FORM
This form may be used as the written report which the law requires all mandated reporters to file with the
Department of Human Services, following an oral report of suspected child abuse. Fill in as much information
under each category as is known. Submit the completed form to the Centralized Intake Unit, PO Box 4826, Des
Moines, Iowa 50305 within 24 hours of the oral report. (DHS hotline: 1-800-362-2178)
FAMILY INFORMATION
Name of child: ____________________________________ Age: _____________ Date of Birth: _____________
Address: _____________________________________________________________________________________
Phone: ____________________________ School:____________________________ Grade Level: ____________
Name of Parent
Phone (if different
or Guardian: ______________________________________________
from child’s): _________________
Address (if different from child’s): _________________________________________________________________
Other Children in the Home:
NAME
BIRTHDATE
CONDITION
INFORMATION ABOUT SUSPECTED ABUSE: In this section, indicate the date of suspected abuse; the nature,
extent and cause of the suspected abuse; the person(s) thought to be responsible for the suspected abuse;
evidence of previous abuse; and other pertinent information needed to conduct the investigation. Use the back of
this form if necessary to complete the information requested above and to identify individuals who have been
informed of the child abuse report, such as building administrator, supervisor, etc.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
REPORTER INFORMATION:
Name and Title or Position: ______________________________________________________________________
Office Address: ________________________________________________________________________________
Phone: ________________________ Relationship to Child: ___________________________________________
Name(s) of other mandatory reporter(s) who has/have knowledge of the abuse: ___________________________
Date Suspected Abuse Occurred: ________________ Date Suspected Abuse Report Phoned in: ______________
Date Suspected Abuse Report Mailed: ____________ Name of DHS Worker Called: ________________________
Verbal Response from DHS Worker: _______________Accepted
_______________ Not Accepted
If the oral report form was not accepted for investigation, this form is not necessary.
Signature of Reporter
Date
HS5053 revised 8/13
SEND COPY TO CENTRAL OFFICE

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