Child Maltreatment Reporting Form Date of Report: 9/22/2019 If you feel this child(ren) is in immediate danger, please call 911. If you are unsure and/or would prefer to speak to a Child Protection social worker, please call Anoka County Child Protection at 763-324-1440 and a social worker will assist you with your report. Child Please provide as much information about the child as possible Child's Name: Date of birth (MM/DD/YYYY): Child's Age: 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 Click To Add Other Children Living In The Home Other Children In Home: Other Child's Age If Known: Parent Please provide as much information about the parent as possible Parent/Guardian: Parent's Age: Parent's DOB (MM/DD/YYYY): Address: City State Zip: Primary Phone: HomeCellWork Secondary Phone HomeCellWork Parent/Guardian: Parent's Age: Parent's DOB (MM/DD/YYYY): Address: Same as above. City State Zip: Primary Phone: HomeCellWork Secondary Phone: HomeCellWork Alleged Perpetrator Please provide as much information about the alleged perpetrator as possible Name of alleged perpetrator: Alleged Perpetrator's Age: Alleged Perpetrator's DOB (MM/DD/YYYY): Relationship To Child: Address: City State Zip: Phone: HomeCellWork Secondary Phone: HomeCellWork Reporter Please provide as much information about the reporter as possible Check if you are a Mandated Reporter. Am I a mandated reporter? * Reporter's Name: * Agency/School: * Address: * City State Zip: * Primary Phone: HomeCellWork Secondary Phone: HomeCellWork Has anyone else been notified of this report? (Police, Parent, Child, etc..) Reason For Referral Please provide a reason for referral. Please include conditions, dates, descriptions of injury, statements of child, etc. * Attach Files You may Choose a image, word or pdf file. Click the Attach Selected File button to submit documents with your referral. Upload Files: Submit Form