Child Maltreatment Reporting Form

Child's Name: Child's DOB (MM/DD/YYYY): Child's Age: Child's Gender: Name of School (or daycare): Grade: -Select Grade- Preschool Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

---

List other children in the home here

Parent/Guardian 1: Relationship To Child -Select Option- Biological Parent Stepparent Guardian Other Parent/Guardian's DOB (MM/DD/YYYY): Parent/Guardian's Age: Parent/Guardian Gender: Address: City, State: Zip Code: Primary Phone:

Home

Cell

Work

Secondary Phone:

Home

Cell

Work

---

Parent/Guardian 2: Relationship To Child -Select Option- Biological Parent Stepparent Guardian Other Parent/Guardian's DOB (MM/DD/YYYY): Parent/Guardian's Age: Parent/Guardian Gender: Address: Same as above. City, State: Zip Code: Primary Phone:

Home

Cell

Work

Secondary Phone:

Home

Cell

Work

---

Child Resides with -Select Option- Parent/Guardian 1 Parent/Guardian 2 Both Parents/Guardians Other

Name of Alleged Perpetrator: Alleged Perpetrator's DOB (MM/DD/YYYY): Alleged Perpetrator's Age: Alleged Perpetrator Gender: Relationship To Child: Where does alleged perpetrator live: -Select Option- Same as Parent/Guardian 1 Same as Parent/Guardian 2 Same as Parent/Guardian 1 and 2 Other Unknown Phone:

Home

Cell

Work

Secondary Phone:

Home

Cell

Work

Is the reporter aware of any American Indian Heritage, Tribal Enrollment, or eligibility for Tribal enrollment for anyone in the family?

Yes

No

Does anyone listed on the report need an interpreter?

Yes

No

Check if you are a Mandated Reporter.
Am I a mandated reporter?

* Reporter's Name: * Agency/School: Email Address: * Agency Address: * City, State: * Zip Code: * Primary Phone:

Home

Cell

Work

Secondary Phone:

Home

Cell

Work

Has anyone else been notified of this report? (Police, Parent, Child, etc..)

Estimated Date of Alleged Maltreatment: If the alleged maltreatment is physical abuse, did the child have injuries? Not Sure Yes No * In the box below please provide a reason for report including conditions, dates, descriptions of injury if noted above, statements of child, etc.(and attach a picture if applicable).

Upload Files:

---