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*

Select

Street Address*

City, State Zip Code*

Phone*

Child's School*

Select

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*

Select

Phone of person reporting the abuse/neglect*

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