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Suspected Child Abuse or Neglect Referral

Notes

If you wish to retain a copy of what you are submitting, please print a copy for your records prior to submitting.

Child(ren)'s Name(s) *

Child(ren)'s Date of Birth and/or Age

Entered into SSIS?

School or Day Care Child(ren) Attend(s)

Parent(s)/Guardian Name(s) *

Parent(s)/Guardian Address

Parent(s)/Guardian Telephone Number(s), if known

City

State

Zip Code

Entered by CRU?

Is parent/guardian aware of report? *

Is child aware of report? *

Last known incident of suspected abuse/neglect and date

Describe concerns/reasons for referral

Did you place a phone call to Social Services Intake?

Who did you speak with?

Date and time you called

First Name

Last Name

Relationship to child

Phone Number

Address

City

State

Zip Code

Are you a mandated reporter?

First Name

Last Name

Phone

Organization

Business Address

City

State

Zip Code

Do you want to be notified of the screening decision?

Did you witness, or observe, these concerns?

If yes, explain. If no, how did you obtain the information?

What are some positives and/or who are some supports for this family?

Are there safety concerns for the children or for someone who may visit the home?

Please include any information about the safety concerns.

What convinced you to call or take action today?

Has something like this happened before, or is there similar history?

If you wish to retain a copy of what you are submitting, please print a copy for your records prior to submitting.

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