2. Date:
   Date:
4. Mandated Reporters Name and Relationship to Child(ren)
5. Email Address
7. Address
9. City
10. State
11. Zip Code
13. Phone Number
14. Fax Number
16. Name of Alleged Victim(s)
17. Date of Birth
19. Address
21. City
22. State
23. Zip Code
25. Phone Number
27. Parent/Guardian Name
28. Address
30. City
31. State
32. Zip Code
34. Phone Number
36. Alleged Perpetrator(if known)
37. Alleged Perpetrators Relationship to Child
39. Address
41. City
42. State
43. Zip Code
45. Phone Number
47. Does the Child(ren) have any American Indian Heritage or Tribal Affiliation?*
    -- Select One --YesNo
48. IF yes, with what Tribe(s) does the child have Heritage or Affiliation?
50. Do you want to be notified if the case was screened in or screen out?
51. Yes or No
    -- Select One --YesNo
53. Mandated Report
    Give nature and extent of the suspected abuse or neglect, including any information of previous abuse or neglect; family composition and any other information which may be helpful in protecting the health and welfare of the child(ren). If additional space is needed, attach additional pages. (BE SPECIFIC. ANSWER: WHO, WHAT, WHERE, WHEN, HOW OFTEN.)
55. Upload Additional Documentation
56. Additional Information to Upload
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

* indicates a required field