Form Dcf-136 - Report Of Suspected Child Abuse Or Neglect

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REPORT OF SUSPECTED CHILD ABUSE OR NEGLECT
DCF-136
Careline
04/2015 (Rev.)
1-800-842-2288
Within forty-eight hours of making an oral report, a mandated reporter shall submit this form (DCF-136) to the relevant Area Office listed below
See the reverse side of this form for a summary of Connecticut law concerning the protection of children.
Please print or type
Child’s Name
Age Or DOB
Race:
American Indian or Alaskan Native
Hispanic
M
Asian/Pacific Islander
White (not of Hispanic origin)
F
Black/African American (not of
Unknown
Hispanic Origin)
Other ____________________
Child’s Address
Name Of Parents Or Other Person Responsible For Child’s Care
Address
Phone Number
Name Of Careline Worker To Whom Oral Report Was Made
Date Of Oral Report
Date And Time Of Suspected Abuse/Neglect
Name Of Suspected Perpetrator, If Known
Address And Phone Number, If Known
Relationship To Child
Nature And Extent Of Injury(ies), Maltreatment Or Neglect
Describe The Circumstances Under Which The Injury(ies), Maltreatment Or Neglect Came To Be Known
Describe the Reasons Such Persons(s) Are Suspected of Causing Such Injuries, Maltreatment of Neglect
Information Concerning Any Previous Injury(ies), Maltreatment Or Neglect Of The Child Or His/Her Siblings
Information Concerning Any Prior Cases(s) In Which The Person(s) Have Been Suspected Of Causing An Injury(ies), Maltreatment Or Neglect Of A Child
List Names And Ages Of Siblings, If Known
What Action, If Any, Has Been Taken To Treat, Provide Shelter Or Otherwise Assist The Child?
REPORTER SECTION
Reporter’s Name And Agency
American Indian or Alaskan Native
Address :
Phone Number
Asian/Pacific Islander
Black/African American (not of Hispanic Origin)
Hispanic
City:
White (not of Hispanic origin)
Prefer Not to Answer
Other _________________________________
Reporter’s Signature
Position
Date
WHITE COPY: TO DCF AREA OFFICE (see below)
IF YOU NEED ADDITIONAL SPACE, YOU MAY ATTACH MORE DOCUMENTATION
Bridgeport
Danbury
Hartford
Manchester
Norwalk
100 Fairfield Avenue
131 West Street
250 Hamilton Street
364 West Middle Tnpk
761 Main Ave
Bridgeport, CT 06604
Danbury, CT 06810
Hartford, CT 06106
Manchester, CT 06040
Norwalk, CT 06821
203-384-5300
203-207-5100
860-418-8000
860-533-3600
203-899-1400
TDD: 203-384-5399
TDD: 203-748-8325
TDD: 800-315-4082
TDD: 800-315-4415
TDD: 203-899-1491
Fax: 203-384-5307
Fax: 203-207-5170
Fax: 860-418-8327
Fax: 860-533-3750
Fax: 203-899-1463, 203-899-1464
Meriden
Middletown
Milford
New Britain
New Haven
One West Main Street
2081 South Main St
38 Wellington Road
One Grove Street, 4th Fl
One Long Wharf Drive
Meriden CT 06451
Middletown, CT 06457
Milford, CT 06461
New Britain, CT 06053
New Haven, CT 06511
203-238-8400
860-638-2100
203-306-5300
860-832-5200
203-786-0500
TDD: 203-238-8517
TDD: 860-638-2195
TDD: 203-306-5604
TDD: 860-832-5370
TDD: 203-786-2599
Fax: 203-238-6287
Fax: 860-346-2585
Fax: 203-777-4358
Fax: 860-832-5318
Fax: 203-786-7457
Norwich
Torrington
Waterbury
Willimantic
Two Courthouse Square
62 Commercial Blvd
395 West Main Street
322 Main Street
Norwich, CT 06360
Torrington, CT 06790
Waterbury, CT 06702
Willimantic, CT 06226
860-886-2641
860-496-5700
203-759-7000
860-450-2000
TDD: 860-885-2438
TDD: 860-496-5798
TDD: 203-465-7329
TDD: 860-456-6603
Fax: 860-885-1300
Fax: 860-496-5746
Fax: 203-759-7296
Fax: 860-423-5034

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