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Suspected Child Maltreatment Report

  1. This form is used as the follow-up written report to the required verbal report by mandated reporters.

  2. Nature of allegation

  3. Please include city, state, and county.

  4. e.g. family, facility, or other

  5. Alleged Victim(s)

  6. Please provide names, DOB, gender, school, phone#, and address.

  7. Include description of injuries, location of injuries, dates and locations of incidents, what was observed, etc.

  8. Parent/Guardian(s)

  9. Alleged Perpetrator(s)

  10. Reporter Information

  11. Please Note

    Due to our website settings, profanity is automatically filtered and use of these words prohibits the sender from submitting the form. Profanity must be removed, or certain letters of these words substituted for characters, in order to send this form.

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  13. This field is not part of the form submission.