Suspected Child Abuse Report Form

CHILD'S NAME:                                                                                                   

DATE OF BIRTH:                                    

ADDRESS:                                                                                                          

PARENT(S)/LEGAL GUARDIAN:                                                                            

SCHOOL:                                                    

ADDRESS:                                                                                                          

I hereby acknowledge that I have a statutory duty to report any suspected abuse to DHS. I further understand that merely filing this report does not absolve me of my statutory duty to report this directly to DHS.

A copy of this suspected child abuse or neglect report may be filed with the Department of Human Services, the supervising administrator and the Superintendent of Schools.

Describe the nature and extent of the suspected child abuse or neglect:

Describe any evidence of previous suspected child abuse or neglect:

Names of persons present during the interview with the child:                                                                                         

Name of investigating social worker with the Department of Human Services (if known):                                                                                         

Signature of Person Filing Report: