Form Dhr-Fcs-1593 - Written Report Of Suspected Child Abuse/neglect
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2STATE OF ALABAMA DEPARTMENT OF HUMAN RESOUCES
WRITTEN REPORT OF SUSPECTED CHILD ABUSE/NEGLECT
Please print or type all known information. The Child Abuse/Neglect Reporting Law and instructions are explained on the back of this form.
SECTION I – CHILDREN ALLEGEDLY ABUSED OR NEGLECTED
NAME (First, Middle Initial, Last)
SEX
ETHNICITY
DATE OF BIRTH/AGE
1.
_________________________________________________________________
M
F
________________ ____________________
2.
_________________________________________________________________
M
F
________________ ____________________
3.
_________________________________________________________________
M
F
________________ ____________________
4.
_________________________________________________________________
M
F
________________ ____________________
5.
_________________________________________________________________
M
F
________________ ____________________
6.
_________________________________________________________________
M
F
________________ ____________________
ADDRESS _______________________________________________________________________________________________________________________
Street Address
City
State
Zip
Telephone Number
SECTION II – OTHER PERSONS LIVING WITH THE CHILDREN (Include parents/custodians and other children in the home)
NAME (First, Middle Initial, Last)
DATE OF BIRTH / AGE
ETHNICITY
RELATIONSHIP TO
THE CHILDREN
1.
________________________________________________________________
____________________ ________________ _________________
2.
________________________________________________________________
____________________ ________________ _________________
3.
________________________________________________________________
____________________ ________________ _________________
4.
________________________________________________________________
____________________ ________________ _________________
5.
________________________________________________________________
____________________ ________________ _________________
6.
________________________________________________________________
____________________ ________________ _________________
SECTION III – PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE OR NEGLECT
NAME (First, Middle Initial, Last)
SEX
ETHNICITY
DATE OF BIRTH / AGE
1.
_________________________________________________________________
M
F
________________
____________________
_________________________________________________________________
______________________________________________________
Street Address
City
State
Zip
Telephone Number
Relationship To Children Allegedly Abused/Neglected
2.
_________________________________________________________________
M
F
________________
____________________
_________________________________________________________________
______________________________________________________
Street Address
City
State
Zip
Telephone Number
Relationship To Children Allegedly Abused/Neglected
SECTION IV – ABUSE OR NEGLECT ALLEGATIONS (Describe what happened, how it affected the children, and the date(s) occurred, if known.
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
Did you see the abuse or neglect when it occurred?
Yes
No
If no, how did you find out about it? ______________________________________
Please identify other people who witnessed the abuse/neglect or who may have information about the child’s or family’s situation.
Name
Address
Telephone #
Relationship to Children
1. ________________________________________ __________________________________________
______________ ________________________
2. ________________________________________ __________________________________________
______________ ________________________
SECTION V - OTHER PERTINENT INFORMATION
________________________________________________________________________________________________________________________________
SECTION VI - REPORTER
_________________________________________________________________________________________________________________________________________________
Name
Address
Telephone Number
Title/Agency/Relationship To Children
Did you verbally report the allegations to the Department of Human Resources or law enforcement?
Yes (specify to whom in section below)
No
______________________________________________
_____________________________________________________
________________________
Name
Name of County DHR, Police Department, or Sheriff’s Department
Date Reported
Signature _______________________________________________________________________ Date ____________________________________________
For DHR Use Only County _______________________________ Case #____________________________ Date Report Received _____________________
DHR-FCS-1593 (September 2002)
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