Child Maltreatment Reporting Form

Child

Please provide as much information about the child as possible

Child's Name:

Child's DOB (MM/DD/YYYY): Child's Age: Child's Gender: Name of School (or daycare): Grade:

Other Child Name	DOB/Age	Gender	School/Daycare
Name	Age	Gender	School

Parent

Please provide as much information about the parent as possible

Parent/Guardian:

Parent's DOB (MM/DD/YYYY): Parent's Age: Parent Gender: Address: City, State: Zip Code: Primary Phone: HomeCellWork Secondary Phone: HomeCellWork Parent Language: Interpreter Needed

Parent/Guardian:

Parent's DOB (MM/DD/YYYY): Parent's Age: Parent Gender: Address: Same as above. City, State: Zip Code: Primary Phone: HomeCellWork Secondary Phone: HomeCellWork Parent Language: Interpreter Needed

Alleged Perpetrator

Please provide as much information about the alleged perpetrator as possible

Name of alleged perpetrator:

Alleged Perpetrator's DOB (MM/DD/YYYY): Alleged Perpetrator's Age: Perpetrator Gender: Relationship To Child: Address: City, State: Zip Code: Phone: HomeCellWork Secondary Phone: HomeCellWork Perpetrator Language Interpreter Needed

Reporter

Please provide as much information about the reporter as possible

Check if you are a Mandated Reporter.

* Reporter's Name:

* Agency/School: Email Address: * Address: * City, State: * Zip Code: * Primary Phone: HomeCellWork Secondary Phone: HomeCellWork
Has anyone else been notified of this report? (Police, Parent, Child, etc..)

Reason For Report

Estimated Date of Alleged Maltreatment: If the alleged maltreatment is physical abuse, did the child have injuries? * 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).

Attach Files

Please attach any pictures (jpeg), pdf, or other documents to support the report

Upload Files:

You will be given the opportunity to print your report after submitting form.