SUSPECTED CHILD ABUSE REPORT FORM
CHILD'S NAME: DATE OF BIRTH: ______________________
PARENT(S)/LEGAL GUARDIAN: ______________________________________________________________
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. The supervising administrator will also need to contact the DHS.
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: _______________________________________________________________
Signature of Supervising Administrator: ___________________________________________________________