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506.4.1P - Suspected Child Maltreatment Reporting Form – Dakota County

506.4.1P - Suspected Child Maltreatment Reporting Form – Dakota County

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__________________________________________________________________________________


Nature of the problem (including victim’s name, injuries and location where incident occurred):










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________________




Draw in the location of the maltreatment if applicable

Please use the space provided below to complete your report


                                                     (front)                                                          (back)



If the report is for:


Suspected abuse or neglect that does involve school personnel as the alleged offender



See Procedure 506.4.2P, Maltreatment of Students Reporting Form - MDE





Suspected abuse or neglect that does not involve school personnel as the alleged offender


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

Suspected kidnapping or depriving another of custodial or parental rights

Send this form to:

Local law enforcement department OR Dakota County sheriff

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