REPORT OF ACTUAL OR SUSPECTED CHILD ABUSE OR NEGLECT

Michigan Department of Health and Human Services

Was Complaint Phoned to MDHHS?

Yes

No

If yes, Intake ID #

If no, contact Centralized Intake 855-***-****) immediately

INSTRUCTIONS: REPORTING PERSON: Complete items 1-19 (20-28 should be completed by medical personnel, if applicable). Send to Centralized Intake at the address listed on page 2.

1. Date

2. List of Child(ren) Suspected of Being Abused or Neglected. To insert additional rows, tab at the end of last row to create a new row.

NAME

BIRTH DATE

SOCIAL SECURITY #

SEX

RACE

Click Here and Type

3. Mother’s Name

4. Father’s Name

5. Child(ren)’s Address (No. & Street)

6. City

7. County

8. Phone No.

9. Name of Alleged Perpetrator of Abuse or Neglect

10. Relationship to Child(ren)

11. Person(s) The Child(ren) Living With When Abuse/Neglect Occurred

12. Address, City & Zip Code Where Abuse/Neglect Occurred

13. Describe Injury or Conditions and Reason for Suspicion of Abuse or Neglect

14. Source of Complaint (Add reporter code below)

01 Private Physician/Physician’s Assistant

11 School Nurse

42 MDHHS Facility Social Worker

02 Hosp/Clinic Physician/Physician’s Assistant

12 Teacher

43 DMH Facility Social Worker

03 Coroner/Medical Examiner

13 School Administrator

44 Other Public Social Worker

04 Dentist/Register Dental Hygienist

14 School Counselor

45 Private Agency Social Worker

05 Audiologist

21 Law Enforcement

46 Court Social Worker

06 Nurse (Not School)

22 Domestic Violence Providers

47 Other Social Worker

07 Paramedic/EMT

23 Friend of the Court

48 FIS/ES Worker/Supervisor

08 Psychologist

25 Clergy

49 Social Services Specialist/Manager (CPS, FC, etc.)

09 Marriage/Family Therapist

31 Child Care Provider

56 Court Personnel

10 Licensed Counselor

41 Hospital/Clinic Social Worker

15. Reporting Person’s Name

Report Code (see above)

15a. Name of Reporting Organization (school, hospital, etc.)

15b. Address (No. & Street)

15c. City

15d. State

15e. Zip Code

15f. Phone Number

16. Reporting Person’s Name

Report Code (see above)

16a. Name of Reporting Organization (school, hospital, etc.)

16b. Address (No. & Street)

16c. City

16d. State

16e. Zip Code

16f. Phone Number

17. Reporting Person’s Name

Report Code (see above)

17a. Name of Reporting Organization (school, hospital, etc.)

17b. Address (No. & Street)

17c. City

17d. State

17e. Zip Code

17f. Phone Number

18. Reporting Person’s Name

Report Code (see above)

18a. Name of Reporting Organization (school, hospital, etc.)

18b. Address (No. & Street)

18c. City

18d. State

18e. Zip Code

18f. Phone Number

19. Reporting Person’s Name

Report Code (see above)

19a. Name of Reporting Organization (school, hospital, etc.)

19b. Address (No. & Street)

19c. City

19d. State

19e. Zip Code

19f. Phone Number

TO BE COMPLETED BY MEDICAL PERSONNEL WHEN PHYSICAL EXAMINATION HAS BEEN DONE

20. Summary Report and Conclusions of Physical Examination (Attach Medical Documentation)

21. Laboratory Report

22. X-Ray

23. Other (specify)

24. History or Physical Signs of Previous Abuse/Neglect

YES

NO

25. Prior Hospitalization or Medical Examination for This Child

DATES

PLACES

26. Physician’s Signature

27. Date

28. Hospital (if applicable)

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

AUTHORITY: P.A. 238 of 1975.

COMPLETION: Mandatory.

PENALTY: None.

INSTRUCTIONS

GENERAL INFORMATION:

This form is to be completed as the written follow-up to the oral report (as required in Sec. 3 (1) of 1975 PA 238, as amended) and mailed to Centralized Intake for Abuse & Neglect. Indicate if this report was phoned into MDHHS as a report of suspected CA/N. If so, indicate the Log # (if known). The reporting person is to fill out as completely as possible items 1-19. Only medical personnel should complete items

20-28.

Mail this form to:

Centralized Intake for Abuse & Neglect

5321 28th Street Court, SE

Grand Rapids, MI 49546

OR

Fax this form to 616-***-**** or 616-***-**** or 616-***-**** or 616-***-****

OR

email this form to adwanv@r.postjobfree.com

1. Date – Enter the date the form is being completed.

2. List child(ren) suspected of being abused or neglected – Enter available information for the child(ren) believed to be abused or neglected. Indicate if child has a disability that may need accommodation.

3. Mother’s name – Enter mother’s name (or mother substitute) and other available information. Indicate if mother has a disability that may need accommodation.

4. Father’s name – Enter father’s name (or father substitute) and other available information. Indicate if father has a disability that may need accommodation.

5.-7. Child(ren)’s address – Enter the address of the child(ren).

8. Phone Number – Enter phone number of the household where child(ren) resides.

9. Name of alleged perpetrator of abuse or neglect – Indicate person(s) suspected or presumed to be responsible for the alleged abuse or neglect.

10. Relationship to child(ren) – Indicate the relationship to the child(ren) of the alleged perpetrator of neglect or abuse, e.g., parent, grandparent, babysitter.

11. Person(s) child(ren) living with when abuse/neglect occurred – Enter name(s). Indicate if individuals have a disability that may need accommodation.

12. Address where abuse / neglect occurred.

13. Describe injury or conditions and reason of suspicion of abuse or neglect – Indicate the basis for making a report and the information available about the abuse or neglect.

14. Source of complaint – Check appropriate box noting professional group or appropriate category.

Note: If abuse or neglect is suspected in a hospital, also check hospital.

15.-19 - Reporting person’s name - Enter the name and address of person(s) reporting this matter.

Contact this candidate