Suspected Child Abuse Report Form printable pdf download

Reporting Phone Number

(541) 693-2700

SUSPECTED CHILD ABUSE REPORT FORM

This does not constitute a complete report. AS A MANDATED REPORTER, YOU ARE REQUIRED TO NOTIFY, BY TELEPHONE OR IN PERSON, DEPARTMENT

OF HUMAN SERVICES – CHILD WELFARE PROGRAM and/or LAW ENFORCEMENT IMMEDIATELY (ORS 419.B.101). Please complete all sections that are

known to you. If information is not known, please indicate “unknown.” Notification of parent(s) is the responsibility of Law Enforcement (LE) or Community Human

Services– Child Welfare Program.

The following is the information you will need when making a verbal report:

Number telephoned: (541) 693-2700 Fax: (541) 693-2703

and/or Law Enforcement (LE) telephoned:

Madras Police Department:

(541) 475-2201

Agency:

DHS Child Welfare Department

Law Enforcement Agency: ______________________

Jefferson County Sherriff Dept: (541) 475-2201

Date and Time of Call: _______________ _ _________

Date and Time of Call: ___________

________

Warm Springs Police Dept:

(541) 553-3272

Name of Person Talked to:___________________________

Name of Person Talked to:_______________________

Emergency Call 911

Today’s Date:

Reporter’s Name/Business Address/Business Phone:

Child’s Name (Last, First , Middle) and Address:

Name of School: ________________________________________________________________

Date of Birth: __________________ Sex ________

Parent/Guardian’s Name (Last, First) and Address:

Telephone Number:

Sibling(s)/Other Children in Home

Name:______________________ DOB: ______

List additional victims/witnesses or others present during disclosure or when behavior/condition was observed (Names, addresses, & phone if known):

Person(s) who first told you of incident, if appropriate (Name, address, relationship to child):

Alleged Perpetrator(s) Name (last, first middle)

Location of Occurrence(s):

Dates(s) Occurred:

Brief description of Incident and/or concern. You must call Community Human Services– Child Welfare Program and/or Law Enforcement with details of concern:

___________________________________________________________________________________________________________

MAKE A COPY OF THIS REPORT FOR YOURSELF AND THE HUMAN RESOURCE DIRECTOR. DO NOT FILE IN CHILD’S SCHOOL RECORDS. SUBMIT

ORIGINAL FORM TO DARRYL SMITH AT THE SCHOOL DISTRICT OFFICE.