Iowa Department of Human Services
REPORT OF SUSPECTED CHILD ABUSE
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. If your agency has a report form or letter format which
includes all of the information requested on this form, you may use the agency format in place of this form.
Fill in as much information under each category as is known. Submit the completed form to the local office of the
Department of Human Services within 48 hours of oral report.
Name of child
Date of birth
Name of parent or guardian
Phone (if different from child’s)
Address (if different from child’s)
OTHER CHILDREN IN THE HOME
INFORMATION ABOUT SUSPECTED ABUSE
In this section, indicate the date of suspected abuse; the nature, extent and cause of the suspected abuse; the persons
thought to be responsible for the suspected abuse; evidence of previous abuse; and other pertinent information needed to
conduct the assessment. 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.
Name and title or position
Relationship to child
Names of other mandatory reporters who have knowledge of the abuse
Signature of reporter
470-0665 (Rev. 10/06)