Report of Suspected Child Abuse/Neglect
Check Type of Referral:
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Suspected Child Abuse
Suspected Child Neglect
Suspected Educational Neglect
Name (Person making oral report to DSS):
*
Referrer's E-mail Address:
*
School:
Position:
Phone Number:
Name of Child:
Grade:
Address (Where the child may be seen):
City:
Zip:
Age or Birth Date (xx/xx/xxxx):
Name of person(s) responsible for child's care (parent/guardian):
Father:
Father's Phone Number:
Mother:
Mother's Phone Number:
Guardian:
Guardian's Phone Number:
Address:
City:
Zip:
List the nature and extent of the current injury to the child and the circumstances leading to the suspicion that the child is a victim of abuse/neglect. Include information concerning previous injury or condition of neglect to this child or other children in this family situation and previous action taken, if any:
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Any other inofmation available to you which would be of aid in establishing the cause of injuries and/or neglect:
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Signature of person originated report
*
Date & Hour of oral report:
Oral report made to (Name of DSS worker):
*
Required