Report of Suspected/Alleged Child Abuse or Neglect

Department of Child Services (DCS) Reporting Number 1-800-800-5556

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Age

Sex

Street Address

City, State Zip Code

Phone

Child's School

Disability/Medications

Behavioral Issues

Mother/Guardian

Mother/Guardian Name

Last, First

Mother - Street Address

Mother/Guardian street address if different from child's

Mother - City, State Zip Code

Mother/Guardian city, state zip code if different from child's

Mother/Guardian Phone

Phone number including area code (###-###-####)

Mother/Guardian Home Phone

Mother/Guardian Work Phone

Mother/Guardian Cell Phone

Is mother alleged perpetrator?

Yes

Does mother know about this DCS report?

Yes

Father/Guardian

Last, First

Father - Street Address

Father/Guardian street address if different from child's

Father - City, State Zip Code

Father/Guardian Phone

Phone number including area code (###-###-####)

Father/Guardian Work Phone

Father/Guardian Home Phone

Father/Guardian Cell Phone

Is Father alleged perpetrator?

Yes

Does father know about this DCS report

Yes

Other children in the home

Please list the other children in the home including their age, date of birth and sex.

Alleged perpetrator if other than parent/guardian

Address of alleged perpetrator

Phone number of alleged perpetrator

Relationship to child

Allegations reported to DCS

Name of person reporting the alleged abuse/neglect

Title of person reporting the abuse/neglect

School of person reporting the abuse/neglect

Phone of person reporting the abuse/neglect

Send me a copy of my responses

Report Abuse