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2. This form is used as the follow-up written report to the required verbal report by mandated reporters.
4. Report Date/Time
   Report Date/Time

   Report Date/Time
6. Law enforcement notified
   Law enforcement notified

   Law enforcement notified
8. Nature of allegation

   1. Physical
   2. Sexual
   3. Neglect
   4. Emotional
   5. Other
10. Place alleged events occurred
    Please include city, state, and county.
12. Setting where events occurred
    e.g. family home, facility, or other
14. Alleged Victim #1
16. First Name
17. Last Name
19. Native American Heritage

    1. Yes
    2. No
20. Tribal Affiliation if Known
22. Date of Birth
23. Gender
24. School
26. Phone Number
27. Location of Alleged Victim
29. Address
31. City
32. State
33. Zip Code
37. Alleged Victim #2
39. First Name
40. Last Name
42. Native American Heritage

    1. Yes
    2. No
43. Tribal Affiliation if Known
45. Date of Birth
46. Gender
47. School
49. Phone Number
50. Location of Alleged Victim
52. Address
54. City
55. State
56. Zip Code
58. Additional Victim Information
    Please provide names, DOB, gender, school, phone#, and address.
62. Description of Alleged Maltreatment
    Include description of injuries, location of injuries, dates and locations of incidents, what was observed, etc.
64. Educational Neglect Family Engagement Efforts (to be completed by school personnel only)
    Include details regarding what efforts the school has made to engage the family to problem solve and eliminate barriers preventing students from meeting attendance requirements.
66. Parent/Guardian #1
68. First Name
69. Last Name
71. Age
72. Date of Birth
73. Relationship to Victim
75. Address
77. City
78. State
79. Zip Code
81. Phone Number
82. Alternate Phone Number
86. Parent/Guardian #2
88. First Name
89. Last Name
91. Age
92. Date of Birth
93. Relationship to Victim
95. Address
97. City
98. State
99. Zip Code
101. Phone Number
102. Alternate Phone Number
104. Other Children or Household Member Information (include first and last name)
106. Alleged Perpetrator #1
108. First Name
109. Last Name
111. Age
112. Date of Birth
113. Relationship to Victim
115. Phone Number
117. Address
119. City
120. State
121. Zip Code
123. Alleged Perpetrator #2 Information

     Enter Perpetrator 2 Information: Full Name, Age, Date of Birth, Relationship to Victim, Phone Number & Address 

125. Prior Contact or Other Information
131. Reporter Information
133. Full Name (reporter)
134. Relationship to Victim
136. Mandated Reporter?

     1. Yes
     2. No
138. Business / Organization Name
140. Address of reporter
142. City (reporter)
143. State (reporter)
144. Zip (reporter)
146. Phone Number (reporter)
147. Alternate Phone Number (reporter)
148. Email Address (reporter)
150. 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.
Leave This Blank:


152. 1. Receive an email copy of this form.
153. Email address

     This field is not part of the form submission.

154. Submit

* indicates a required field