Adopted: April 2011
Revised: April 2016
Download 506.4.1P - Suspected Child Maltreatment Reporting Form – Dakota County
MINNESOTA STATUTES SECTION 626.556: A person who knows or has reason to believe a child has been neglected or physically or sexually abused shall make an oral report IMMEDIATELY by phone to be followed within 72 hours, exclusive of weekends and holidays, by a report in writing. Please fill out form as completely as possible.
Date of Incident__________ Suspected Maltreatment: □ Physical Abuse □ Sexual Abuse □ Neglect
□ Threatened Injury □ Mental Injury □ Prenatal Exposure □ Other: ___________________________
Reporter’s Information:
Reported by_________________________ Agency________________________________________ Date_______________
Address ______________________________________________________ Telephone_________________________________
Relationship to the family__________________________________________________________________________________
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Nature of the problem (including victim’s name, injuries and location where incident occurred): |
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Where is the child(ren) now?________________________ Caretaker(s) aware of the complaint? ___Yes ___No
Who else did you contact? _________________________________________________________________________________
Others with information ___________________________________________________________________________________
Parent(s)/Guardian(s) Gender □ M □ F DOB Gender □ M □ F DOB
Name(s) __________________________________ _______________________________________
Address __________________________________ _______________________________________
Home Phone __________________________________ _______________________________________
Employment __________________________________ _______________________________________
Work/Cell Phone __________________________________ _______________________________________
Other Names Known By __________________________________ _______________________________________
Previous Spouse __________________________________ _______________________________________
Full Names of Children
Name Gender D.O.B. School Attending
_______________________________ Male/Female __________ ____________________________
_______________________________ Male/Female __________ ____________________________
_______________________________ Male/Female __________ ____________________________
Made Oral Report to________________________________ Date______________ Time________________
OVER
Draw in the location of the maltreatment if applicable
Please use the space provided below to complete your report
(front) (back)
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If the report is for: |
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Suspected abuse or neglect that does involve school personnel as the alleged offender
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See Procedure 506.4.2P, Maltreatment of Students Reporting Form - MDE
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Suspected abuse or neglect that does not involve school personnel as the alleged offender
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Send this form to: Dakota County Social Services, Child Protection Intake Phone: 952-891-7459 Fax: 952-891-7192 OR TO: Local law enforcement agency |
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Suspected kidnapping or depriving another of custodial or parental rights |
Send this form to: Local law enforcement department OR Dakota County sheriff |
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Child’s death a result of neglect or physical or sexual abuse |
Send this form to: medical examiner OR coroner |
Copy to:
School Confidential File, Suspected Maltreatment of a Minor