Child Abuse Reporting Form Child & Family Services URGENT: For any child who is currently in danger of serious injury, or is suspected to be currently in danger of serious injury, please stop now and call law enforcement. Immediate Safety Screening Are any of the below questions true regarding the situation you are reporting? If so, please call 1-855-323-3237 and do not use the online reporting form. Has the child’s parent/caregiver said they may cause serious harm to the child? Does the child have visible injuries from abuse or neglect? Did the child tell you they are being abused or neglected, and they are afraid to go home? Has the child been admitted to a hospital due to abuse or neglect? Is there a report of sexual abuse or serious physical abuse and the alleged perpetrator has access to the child? Is there an active meth lab in the home? Is a newborn having adverse effects due to substance abuse by the mother during pregnancy? Is there a suspicious or unexplained death of a child in the home? Does the child need emergency treatment (medical or psychological) and the parents/caregiver are unavailable or refusing to get treatment? Is there no caregiver available for the child and they are unable to care for themselves? Has law enforcement or a physician taken protective custody of a child? Are you a member of law enforcement and need assistance at the scene? Do any of the above questions apply to your concerns?* YesNo Please stop now and contact us at 1-855-323-3237 for immediate assistance, or call law enforcement. Your Information First Name* Last Name* Phone* Email* Relationship to Alleged Victim Agency/Organization Incident Details What happened?* Where did it occur? When did the incident occur? Is it ongoing? YesNoUnknown Has the alleged victim seen a medical or mental health provider related to the abuse/neglect? YesNoUnknown Is the alleged victim in foster care, or were they at the time of the incident? YesNoUnknown Alleged Victim First Name* Last Name Age (if known) DOB (if known or estimated) Gender Disabilities or special needs (if known) Address of residence* School/Daycare (if known) Names, ages or DOB of siblings in the home (if known) Are there any other alleged victims? YesNo Additional Alleged Victim First Name Last Name Age (if known) DOB (if known or estimated) Gender Disabilities or special needs (if known) Address of residence School/Daycare (if known) Names, ages or DOB of siblings in the home (if known) Parent/Guardian Information Parent/Guardian first name Parent/Guardian last name Parent/Guardian Phone Parent/Guardian Address Relationship to Alleged Victim Date of birth or age (if known) Employment (if known) Is there a second parent or guardian to report? YesNo Additional Parent/Guardian Information Parent/Guardian first name Parent/Guardian last name Parent/Guardian Phone Parent/Guardian Address Relationship to Alleged Victim Date of birth or age (if known) Employment (if known) Is the person alleged to have caused abuse/neglect a parent/caregiver listed above? YesNo Person alleged to have caused abuse or neglect First Name Last Name Age (if known) DOB (if known or estimated) Gender Address (if known) Phone (if known) Employment (if known) Relationship to Alleged Victim(s) Does this person still have access to the victim?* YesNoUnknown Add another alleged perpetrator? YesNo Second Alleged Perpetrator First Name Last Name Age (if known) DOB (if known or estimated) Gender Address (if known) Phone (if known) Employment (if known) Relationship to Alleged Victim(s) Does this person still have access to the victim?* YesNoUnknown
