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Child Protection Report Form

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Suspected Child Abuse/Neglect Report
(Please fill in as many fields that you can)

Child(ren) in the Home:
Name:
Victim: Yes     No
Sex:
DOB or Approx Age:
Address (if different then guardian)

Name:
Victim: Yes    No
Sex:
DOB or Approx Age:
Address (if different then guardian)

Name:
Victim: Yes     No
Sex:
DOB or Approx Age:
Address (if different then guardian)

Name:
Victim: Yes     No
Sex:
DOB or Approx Age:
Address (if different then guardian)
Parent(s) or Guardian:
Name:
Relation:
Sex:
DOB or Approx Age:
Address:
 
Phone:  		 Name:
Relation:
Sex:
DOB or Approx Age:
Address: 

Phone:  

Person believed responsible for abuse/neglect:
Name:
Relation:
Sex:
DOB or Approx Age:
Address:


 Name:
Relation:
Sex:
DOB or Approx Age:
Address:
Current Concern:  Describe the nature and extent of the current abuse/neglect.  What was seen, heard, when incident occurred.  Who was present.
 

How do you know this information?


What impact is there on the child/children?


Is the child(ren) in any present danger?  How long has this been going on?

 
Other:  Information concerning previous abuse/neglect to this child(ren), including previous action taken.  Any other information available, which would be helpful in assessing this situation.

 

I have photos and/or video

I have additional information - please contact me
Reporter:

In accordance with M.S. 626.556, the name of the person or agency reporting child abuse or neglect shall not be disclosed to the subject of the report while the report is under assessment. Upon completion of the assessment, the name of the reporting party shall be confidential and shall be disclosed only upon court order.

Name:
Phone:
Address:

Mandated Reporter:
Yes     No       If yes, Organization/Profession:    
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