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Child Maltreatment Reporting Form

2. Child Maltreatment Reporting Form

4. Date of Report:*
   Date of Report:

6. If you feel the child/ren is in immediate danger, please call 911. If you are unsure and/or would prefer to speak to a Child Protection Social Worker, please call Chisago County Child Protection Intake at 651-213-5672 and the intake specialist will assist you.

8. Date of Incident:*
   Date of Incident:

10. Report By:*

11. Agency:*

    If Mandated Reporter enter Agency Name, otherwise enter N/A.

13. Address:*

    If Mandated Reporter use Agency Address.

15. City:*

16. State:*

17. Zip:*

19. Telephone: (best number to contact you if there are follow-up questions)*

20. Fax Number:

22. Relationship to the Family:

24. Nature of Problem (including victim's name(s) injuries, and location where incident occurred). Please be as detailed as possible.*

26. Location of child/ren now:*

27. Do the parents know you are making a CP report?*

    1. yes
    2. no

29. Does the child know you are making a CP report?*

    1. yes
    2. no

30. Who else have you contacted?

32. Others with information:

34. MOTHER'S INFORMATION

36. Mother's Name:

    Enter FULL (First, Middle, and Last) Name.

37. Date of Birth:
    Date of Birth:

39. Phone #1 (Preferred):

40. Phone #2 (Alternate):

42. Address:

44. City:

45. State:

46. Zip:

48. FATHER'S INFORMATION

50. Father's Name:

    Enter FULL (First, Middle, and Last) Name.

51. Date of Birth:
    Date of Birth:

53. Phone #1 (Preferred):

54. Phone #2 (Alternate):

56. Address:

58. City:

59. State:

60. Zip:

62. Custodial Parent:

64. MOTHER'S HOME. Other Adults residing in the home (i.e. step parent, grandparents and so on):

66. Name:

67. Date of Birth:
    Date of Birth:

69. Name:

70. Date of Birth:
    Date of Birth:

72. Name:

73. Date of Birth:
    Date of Birth:

77. FATHER'S HOME. Other Adults residing in the home (i.e. step parent, grandparents and so on):

79. Name:

80. Date of Birth:
    Date of Birth:

82. Name:

83. Date of Birth:
    Date of Birth:

85. Name:

86. Date of Birth:
    Date of Birth:

88. Is the child or anyone in the family of American Indian or Alaskan heritage?*

    1. yes
    2. no

89. If yes, which family member:

91. Full Name of Child 1 (in the home):

93. Race of Child 1:
    -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHIspanic/LatinoDeclinedUnknown

94. DOB of Child 1:
    DOB of Child 1:

95. Gender

    1. Male
    2. Female
    3. Other

97. School/Daycare of Child 1:

101. Full Name of Child 2 (in the home):

103. Race of Child 2:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown

104. DOB of Child 2:
     DOB of Child 2:

105. Gender

     1. Male
     2. Female
     3. Other

107. School/Daycare of Child 2:

111. Full Name of Child 3 (in the home):

113. Race of Child 3:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown

114. DOB of Child 3:
     DOB of Child 3:

115. Gender

     1. Male
     2. Female
     3. Other

117. School/Daycare of Child 3:

121. Full Name of Child 4 (in the home):

123. Race of Child 4:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown

124. DOB of Child 4:
     DOB of Child 4:

125. Gender

     1. Male
     2. Female
     3. Other

127. School/Daycare of Child 4:

131. Full Name of Child 5 (in the home):

133. Race of Child 5:
     -- Select One --Caucasian/WhiteBlack/African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic/LatinoDeclinedUnknown

134. DOB of Child 5:
     DOB of Child 5:

135. Gender

     1. Male
     2. Female
     3. Other

137. School/Daycare of Child 5:

141. Who has the child identified as the alleged perpetrator of abuse/neglect (if any, please don't specifically ask the child):

143. Name:

144. Phone Number:

146. Address:

148. City:

149. State:

150. Zip:

152. Did you place a phone call to Child Protection Intake?*

     1. yes
     2. no

153. If yes, whom did you speak with?*

     If you did NOT call Child Protection Intake, please enter N/A.

155. Date you called Child Protection Intake?
     Date you called Child Protection Intake?

     If you called Child Protection Intake this field is required.

157. Maltreatment of Minors Act (626.556) requires mandated reporters to provide both verbal and written notice to child protection.

159. ATTACH FILES: Please attach any pictures (jpeg), pdf, or other documents to support the report. If unable to attach files, fax to 651-213-5686.

161. File #1:

162. File #2:

163. File #3:

164. File #4:

166. Contact Information:
     Chisago County Child Protection Intake -- 313 North Main St, Suite 239 -- Center City, MN 55012 -- Phone: 651-213-5672 -- Fax: 651-213-5686 -- Email: chisagocountyprotectionintake@chisagocounty.us

     Chisago County Child Protection Intake -- 313 North Main St, Suite 239 -- Center City, MN 55012 -- Phone: 651-213-5672 -- Fax: 651-213-5686 -- Email: chisagocountyprotectionintake@chisagocounty.us

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