Child Protective Services Reporting Form Indiana Child Abuse & Neglect Hotline: 1-800-800-5556

Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 1

Child Protective Services Reporting Form

Indiana Child Abuse & Neglect Hotline: 1-800-800-5556

As of July 1, 2017, IC 31-33-5-2 now requires the school employee to immediately report suspected child abuse or neglect to the Department
of Child Services (DCS) or to a local law enforcement agency, and then notify the principal or principal’s designee that a report has been
made. The new law requires the first person in the school to be informed of the suspected child abuse or neglect be the person who should
report the matter immediately. Follow up calls can be made if necessary.

Name of DCS representative taking report:__________________ Date of report:____________ Confirmation #:________


Person(s) making observations & report:_______________ Date of Occurrence of suspected abuse/neglect: ______________

Student name:____________________ Grade: __________ DOB: _____________ Age: _____


Sex: ____ Race: _________
School Address/Phone #: __________________________________________________________
Home Address: __________________________ Phone #: ____________________________

Mother’s Name: __________________________ Phone #: ____________________________


Address:________________________________________

Father’s Name: ___________________________ Phone #: ____________________________


Address: ________________________________________

Date person(s) making report were made aware of abuse or neglect: ______________
Person with whom the student lives (if other than parent(s)): ___________________

Other children in the Home with parent/guardian | Name/age

__________________________ ______ ___________________________ ______


__________________________ ______ ___________________________ ______
__________________________ ______ ___________________________ ______
__________________________ ______ ___________________________ ______

Specific description of the student’s alleged injury, abuse, or neglect:


______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Identity of the person(s) alleged to have caused injury, abuse, or neglect: ______
Is the person(s) alleged to have caused the injury, abuse, or neglect a [your school name here] employee? Y___ N___
If yes, name and position:_________________________________
Is the person(s) alleged to have caused the injury, abuse, or neglect a [your school name here] student? Y___ N___
If yes, name and grade:__________________________________
Alleged perpetrator’s address if other than parent/guardian: _______________________
Did the incident occur in school, on school grounds, at a school-related activity, or on the bus?_____________
Description of any known previous injuries, abuse, or neglect: ______________________

Are there any drugs/weapons in the home?_________ Are there any pets/dangerous animals in the home?__________
Has there been any domestic violence in the home?__________
Is there anyone in the whole who uses drugs or other behavior altering substances?___________
Are you aware of anyone living in the home who is involved in gang activity?___________

____Screened in for assessment ____Screened out for assessment

Principal’s Signature____________________ Date:________


[your school name here] Reporter Signature:____________________ Date:________

Date entry made on Student Health Record on: _____________ by:________________

You might also like