Report of Suspected Child Abuse/Neglect

Check Type of Referral: *

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: *

Any other inofmation available to you which would be of aid in establishing the cause of injuries and/or neglect: *

Signature of person originated report *

Date & Hour of oral report:

Oral report made to (Name of DSS worker):

* Required